Chapter 1

ICCA 2017

Social Issues of the Childhood

Child at the centre of the debate

Conference Ebook

Porto, Janeiro 26 a 28, 2017 / Oporto, January 26th to 28th 2017

1º Congresso Internacional da Criança e do Adolescente, Porto 26, 27 e 28 de Janeiro, 2017 1st International Conference on Childhood and Adolescence, Porto, 26th, 27th and 28th of January, 2017

EventQualia

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ISBN: 978-989-54102-0-1

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Alexandra Vasconcelos (SPS-SPP)

Deolinda Barata (SPS-SPP)

Filipa Pancada Fonseca (HFF)

Helena Isabel Almeida (SPS-SPP)

Idalina Machado (FLUP)

Isabel Monteiro (ESS-UA)

Margarida Tavares (SPS-SPP)

Maria de Lurdes Torre (SPS-SPP)

Maria do Carmo Pinto (SPS-SPP)

Maria Manuel Zarcos (SPS-SPP)

Marta Ezequiel (HFF)

Paula Guerra (FLUP)

Raquel Leitão (ESE-IPVC)

Sara Melo (ISSSP)

Sérgio Costa Araújo (ESE-IPP)

Comissão Científica // Scientific Committee

Alexandra Vasconcelos (SPS-SPP)

Bela Franchini (FCNAUP)

Carla Cardoso (FDUP)

Carla Faria (ESE-IPVC)

Deolinda Barata (SPS-SPP)

Helena Isabel Almeida (SPS-SPP)

Idalina Machado (FLUP)

Isabel Dias (FLUP)

Isabel Monteiro (ESS-UA)

José Carlos Santos (ESEnfC)

José Tenente (FADEUP)

Josefina Castro (FDUP)

Manuela Sanches Ferreira (ESE-IPP)

Margarida Tavares (SPS-SPP)

Maria de Lurdes Torre (SPS-SPP)

Maria do Carmo Pinto (SPS-SPP)

Maria Manuel Zarcos (SPS-SPP)

Natália Fernandes (IE-UM)

Neide Urbano (HDE)

Olga Vasconcelos (FDAEUP)

Óscar Ribeiro (DEP-UA e ISSSP)

Paula Guerra (FLUP)

Raquel Leitão (ESE-IPVC)

Sara Melo (ISSSP)

Sérgio Costa Araújo (ESE-IPP)

Teresa Gonçalves (ESE-IPVC)

Sobre o Congresso

O Congresso Internacional da Criança e do Adolescente, sob a organização da Secção de Pediatria Social da Sociedade Portuguesa de Pediatria (SPS-SPP), da eventQualia e da SPECAN (Sociedade Portuguesa para o Estudo da Criança Abusada e Negligenciada), promove o diálogo aberto sobre as questões da Infância e Adolescência, através do cruzamento de perspetivas multidisciplinares e experiências diversificadas sobre o tema. Ancorado numa abordagem participativa, na qual a audiência pode e deve tomar parte do debate, o ICCA potencia o encontro entre o saber e o saber-fazer nas mais variadas áreas, desde a Psicologia à Medicina, passando pelo Direito, Artes, Desporto, Serviço Social, Enfermagem, Nutrição, entre muitas outras; colocando em contacto investigadores, técnicos, profissionais, estudantes, professores, pais e todos os interessados nestas matérias, que têm agora oportunidade de se lançar no debate de temas fundamentais e pertinentes na realidade atual. 

Contando já com duas edições de sucesso, com mais de cinco centenas de participantes, o ICCA tem ganho reconhecimento além fronteiras, reunindo participantes oriundos dos cinco continentes que partilham as suas experiências e conhecimentos em três dias de programação multidisciplinar e abrangente. Assim, acreditamos que estão reunidas todas as condições para que as próximas edições sejam igualmente bem-sucedidas, com a promessa de novos temas de discussão, novos oradores, e a mesma vontade de proporcionar uma experiência única e memorável.

About the congress

The International Conference on Childhood and Adolescence is organized by eventQualia together with the Social Paediatric Subcommittee (SPS-SPP) of the Portuguese Society of Paediatrics and the Portuguese Society for the Study of Abused and Neglected Children (SPECAN).

The conference has the main goal of promote a discussion on the social issues of childhood, introducing innovative  discussion formats which are more open to the active participation of the audience. Besides, the International Conference on Childhood and Adolescence  intends to put on an open dialogue researchers, students and technicians from different areas, like Sociology, Psychology, Social Paediatrics, Education Sciences, Social Service, Nutrition Sciences, Sport Sciences, among others. The multidisciplinary approach is one the great advantages of this conference, which allows the participants to establish contact with other perspectives and points of view, as well as share experiences and knowledge. After a successful first edition, ICCA 2018 gathered nearly 560 participants in a  healthy discussion environment about some of the most relevant issues regarding childhood and adolescence. We will return next year, with new topics for debate, new speakers, and the same commitment of provide a memorable moment of sharing knowledge and experiences!

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Chapter 2

Education

Bullying, the Child at Risk

Amália Rebolo

ISET, Instituto Piaget - Almada; RECI (Research in Education and Community Intervention)

Abstract​
School bullying implies the presence of negative relationships based on the power of one (or group) over another (or others) in a repeated and intentional way with the purpose of causing suffering. These relationships mainly occur among children and young people belonging to the same class, the aggressions are more or less indirect and can be repeated for prolonged periods of time due to the victim's inability to defend himself or to seek help. In addition to aggressors and victims, often there are observers: some support or help the aggressors while others support or would like to help the victim; sometimes they take part in the incidents trying to reduce the negative effects. In a study on Play Fight and Serious Fight (Rebolo Marques, 2006), 83 children were observed and interviewed, 54 of them considered as direct participants in conflicts and aggressions by classmates as aggressors (30), victims (11) or both (13). Five years after this data collection their levels of school success were analyzed and was found that the perpetrators had the highest levels of school dropout and retention (50%) followed by the victims (27%) and the percentage of retention was significantly lower in the other groups in analysis. The experience of bullying seems to be associated with school failure. Student retention decisions should be given greater attention and discussion by parents and guardians as first educators, teachers, decision-makers at the school level and by policy makers.

Keywords: education; bullying; retention; Drop out

Introduction

School bullying is a recurring theme in the media whenever something more serious or visible happens. However, most situations are in the "secret of the gods" or more properly "in the secret" of the participants in the situations. When we talk about school bullying we are talking about negative relationships based on the power of one (or one group) over another (or others). Direct and indirect provocations are intentional and repeated in order to cause suffering and mainly occurring among classmates. The duration of this type of peer violence may vary in duration depending on the victim's inability to defend or seek help. From the first studies started in the 1970s by Olweus (1993) and Whitney & Smith (1993), the identification of risk factors was the main objective - characteristics of offenders and victims, places of residence, schools, family conditions, etc. At the beginning of the 21st century, the identification of potential aggressors and victims continues to make sense so that prevention and intervention strategies can be implemented. Maladaptation to school, depression and school drop-out by the victim have been identified among the negative effects of bullying. In relation to the aggressors, when identified, they are subject to disciplinary sanctions ranging from simple admonition to the change of school, more often these students are punished with the accomplishment of tasks of support to the operational assistants or prevented from entering the school (suspension) between 1 to 10 days (in Portugal). Aggressors and victims find it hard to achieve school goals, the firsts because of their disruptive behaviour, irregular attendance and frequent punishment, the victims because of school integration difficulties, fear and sometimes depression.

The participants ​
It is consensual that the relationship of bullying implies the presence of aggressors and victims. However not all aggressors want to hurt and not all victims are innocent in the situations in which they engage. Some aggressors are only children / young people who react aggressively to contextual circumstances they feel as provocations such as being assaulted or when they see a friend being the target of aggression. These aggressors are often seen as cooperative or ambiguously loved by some of the class mates and distrusted by others. Some victims are provocative and they start the unpleasant situations in which they are involved, they seem to seek the contact through the challenge and risk. These victims get some attention when they are mistreated by their colleagues.

To preserve the relationship that we call bullying the aggressor seeks conflict almost always with a guarantee of success, he chose his victim among the most fragile of the class or school, and he knows that they will be afraid, sometimes in pain but they will not ask for help. Usually the victims have no friends or they have asked for help without any result in their favor or they simply believe that bad things happen because of them. Often the aggressor has his support group that concretizes the aggressions and / or covers his.​
Others involved are almost unknown, but their actions may be fundamental. The observers are out of the incident, but can assume distinct roles with different effects on the results and effects of the incidents. Some observers just observe, avoid being noticed so as not to be called to testify about any fact, pretend nothing happened. Other observers are part of the group that supports the aggressor and may assist him in the aggression or just observe (which in any case shows the victim his / her fragility and probably his / her fault in the incident). Some observers would like to help the victim, but do not do so for fear of being the next victim or for fear of being excluded from the groups of friends. Other observers assume positions of support and defense the victim; these observers avoid the negative effects and show the victim their support.

Bullying effects

Although it is not always possible to establish the relationship between cause and effect, it is recognized that both aggressors and victims have difficulty in achieving school goals.

About victims, difficulties in adapting to school and fear frequently lead to depression and dropping out of school. "Unimportant" situations like being taken for the family name can provoke great dissatisfaction and will of revenge which in turn can lead to aggression.​
Aggressors, because of their often disruptive behavior, irregular participation in school and the fact that they are often undisciplined as well as being aggressors towards their colleagues, are often subject to disciplinary sanctions (from simple admonition to school change).​
School Bullying and Socialization

The quality of the relations is related to the interaction behaviors according to the contexts (Ladd & Price, 1993, p.130). In school, it is important to be socially accepted and to have friends which allows participation in activities and avoids isolation. The lack of social acceptance can aggravate isolation and promote aggression and disinterest. Peer relationship difficulties may be associated with school dropout and juvenile and adult delinquency (Parker & Asher, 1987).

Children know who they like to be with and identify those they do not like. That identification allows the educators to categorize the members of a group into sociometric status types taking into account positive and negative nominations. Popular children have many positive appointments and few or no negative appointments; Controversial children are those who have many positive and many negative nominations; Rejected children have many negative appointments and few or no positive appointments; Neglected children are those who do not receive nominations (positive or negative) (Smith et al., 1994, p 197).

Sociometric techniques allow us to identify the relationships between the members of the groups and we can expect the groups of belonging to show some kind of behaviors. In addition, the children who are rejected and controversial are seen more often as aggressors, victims, or both by their peers (Coie & Dodge, 1988, Newman and Newman 1991, Boulton & Smith 1994, Sharp and Smith 1994, Smith et al. 1995).​
Ladd (1983) and Price & Dodge (1989) found that less cherished children showed greater aggression (in particular reactive aggression), which may lead to the withdrawal of the pairs.

Study

To identify the sample, all 304 primary school students from a primary school in the metropolitan area of ​​Lisbon answered the peer nomination questionnaire of Angulo, Neto & Ortega (2001). The anonymous questionnaire allowed to select for observation and interview the children (n = 83) most named in each class in each category: Aggressors - 30 boys; Victims - 8 boys and 3 girls; Aggressive victims - 12 boys and 1 girl; Conflict managers - 8 boys and 4 girls; Support to the victim - 4 boys and 6 girls; Observers - 3 boys and 2 girls; And not involved - 1 boy and 1 girl.

The risk group (and therefore of greater interest) is made up of 54 children (17.6% of the sample) who are considered (by their pairs and in some cases by their own) directly involved in bullying situations: 9.8% of the children who answered the questionnaires are considered as aggressors by the peers; 3.6% of the children are considered victims and 4.2% are named both as aggressors and as victims.

The students of the sample were observed with continuous video recording (30 minutes) in three non-consecutive recreational times. After each recess, the students filmed and the colleagues with whom they had interacted with viewed the videos and discussed the incidents and situations observed - conversations, pauses, games, fights. The participants made possible to categorize each episode according to their information about play fighting (peaceful, positive) or serious fight (negative, aggressive, violent behavior).

Participants identified 100 episodes of serious fighting. With the collaboration of the children it was possible to see that the they get involved in a unique way taking into account the category groups where the peer nominations put them: the perpetrators caused 51% of the fights in which they got involved (in a set of 49 episodes) while provocative (or aggressive) victims caused 72% of the serious fights they engaged in (in a set of 29 episodes). Children included into all other groups in the global sample have only initiated five serious fights and have reacted in eleven provocative situations.​
Groups and sociometric status​
All students also answered a sociometric questionnaire that included the questions:

• Who are the classmates in your class that you like to play with during recess?

• Who are the classmates in your class that you do not enjoy playing with during recess?

The results presented in table 1 in relation to the groups aggressor, provoking victim and victim confirm the relation between the status of the students in the class and the groups in which they are included in the sample.

Aggressor Group ​
There was an inversely significant correlation between being nominated as a playmate (p <.05) and a very significant relation to rejection at both the nomination and value level (p <.0005). These are children with few or no friends and more classmates in their class who did not like to play or to be with them during break time.

Provocative victim group

There were no significant relationships with play choices but significant relationships were found at rejection level (number and value of rejections). They are rejected by their colleagues

Victim Group ​
There was a significant relationship with the number of choices as a playmate although they were not highly valued (they were not the first choices) and therefore there was no significant relationship with their value.

Table 1: Pearson's correlation coefficient between groups and sociometric status (Rebolo Marques, 2016, p. 109)

*p<.05 **p<.025 ***p<.005 ****p<.0005​
As in Rebolo Marques (2006) sample, the behavioral and aggression problems of the children rejected by the peers are reported by Serbin et al. (1993), Smith et al. (1994) and Hymel et al. (2004, 276). The children included in the Aggressor and Provocative Victim groups seem to face the same rejection problems observed by Coie & Dodge (1988), Boulton & Smith (1994), Sharp & Smith (1994) and Hymel et al. (2004).​
Without friends and with many rejections

Using the Bronfenbrenner table (Cerezo, 2001, page 80), it was identified the status of the students in the sample in each class. Some children were standing at the extreme of choice and rejection. Most students were in an average position, with classmates picking them up for play, but also with some rejection appointments. The cases considered extreme are found in both directions: positive - several choices and no rejection; negative - no choice and several rejections.

Some children had no nomination at the level of play choices and had up to 6 nominations at the rejection level (Rebolo Marques, 2006). This group included: 5 boys belonging to the aggressor group; 2 girls from the victim group; and 2 boys belonging to the provocative victim group. These children seemed to have no friends to help them, or to support during tricky situations in the playground, and there was a group of colleagues in their class who did not accept their presence. I was also identified the most serious cases, which were considered negative extremes, of children who were not nominated by any colleague as a playmate and had 8 or more nominations at the rejection level: PFb09 (8 rejections with total value of 18) and JBc06 (9 rejections with total value of 17) that are two boys belonging respectively to the aggressor group; LSd05 (10 rejections with total value of 23) and KNc19 (13 rejections with total value of 36) that are two boys of 4th grade belonging the first to the victim group and the second to the provocative victim group. It is surprising that the child with the highest rejection rate is considered a provocative victim by his or her classmates

5 Years latter

Five years after collecting data Rebolo Marques (2016) needed to know the school trajectory of the students in the sample, the cases identified above were especially concerned about three students:

- PFb09 – Was repeating the 6th year without success and would be retained again;

- LSd05 – Attended an education course which he abandoned;

- JBc06 – Had repeated the 3rd grade of schooling;

- KNc19 – Had been retained in grade 4 and had moved to another school the following year.

In relation to the total number of participants in the study, Rebolo Marques (2016) tried to know the school paths, the success / failure levels considering the groups in which they were included in the sample. The groups’ aggressor, victim and provocative victim were studied in isolation; all the other students were grouped in the same group (table 2).

It was not possible to obtain information about students who changed schools. It was verified that it is in the Provocative Victim group that there were more school changes, it would be interesting to have more information about their courses, it is not possible to say that children who frequently change schools have greater difficulty adapting, but this is something to consider.

Table 2: School trajectory of sample students five years after initial data collection (Rebolo Marques, 2016, p. 114)

The Aggressor and Victim groups appear to be at higher risk of early school leaving. In the sample, it corresponds to 10% of the aggressors and 9% of the victims. As for the causes of abandonment, it was possible to know from a somewhat informal way that the youths started by presenting irregular attendance and very weak school levels, without interest in the school and finally stopped attending classes. Contacts with the caretakers and attempts to include them into classes with alternative curricula did not have the desired effects. It would be interesting to see if these dropouts are related to the aggressive, provocative and bullying experiences they experienced during their school days.

About retention, students named as aggressors appear to have greater risk of retention, which implies re-attending the same year in another class of younger students. Five years after the data collection, 40% of the aggressors had already repeated one or more years of schooling. Saraiva et al. (2011) report that students with insufficient school performance can start a deviant process more easily. When retained the change of class and the age gap with the new colleagues can cause greater difficulties of integration and acceptance.

The aggressors had the highest dropout and retention levels (50%) followed by the victims (27%). The experience of bullying seems to be associated with school failure (also referred to by Pereira (2002) and Melim (2011)

The identification of the characteristics that could be associated with greater or lesser risk of involvement in bullying situations, should help educators prevent violent relationships in school.

Conclusions

The nomination of peers allowed the identification of the relationships between the children in the classes and the children at risk of involvement in situations of aggression / bullying. The use of this methodology in the teaching activity would allow the identification of children and young people at risk and prevent aggressive behavior, failure and school dropout.

Considering the data, it seems possible to affirm that when a child or young person is retained as a remediation measure it is important the accompaniment to facilitate the integration in the new group. Difficulty in relating to younger children may be one of the causes of socialization problems and lead to aggressive behavior.

On the other hand, children who demonstrate aggressive behavior early on - because they react or because they provoke - can be accused as aggressors. This aspect was verified in the sample since the first-grade students of the group identified as aggressors some children of their classes. Being identified by their peers from a very early age, the aggressors are idolized as heroes by some while others fear them and move away.

The provoking victims seem to have difficulty interacting and so the provocation seems to be their way of interacting with others by drawing attention and waiting for a reaction.

Regarding the school pathways, it is showed that the Aggressors and Victims of the sample had higher levels of retention and dropout than all other children. Surprisingly, the provoking victims have similar levels of success as the other groups in the sample, although the difficulties in relation (difficulties that were observed and not yet perceived) they succeeded in achieving satisfactory levels of schooling and continued schooling without retentions that would delay the conclusion of basic education.

It seems that early intervention is essential to prevent aggressive behaviors that can turn into bullying-type relationships. Prevention can be broad, targeted at the educational community, but should also be focused on students considered to be at risk. Through the application of peer nomination questionnaires, it is possible to identify students at risk, but this form of information collection should be used in conjunction with observation of interactions in classroom and play space.

In bookstores, in millions of sites and in the social networks it is possible to find all the necessary information for parents, students and teachers so that they can identify bullying situations, include lists of aspects to consider and of symptoms to pay attention. The same documents present strategies for behavior management and reaction to provocations. However, it seems to lack information about prevention that should start at the pre-school level. Even these children are already able to identify friends and others, know who they like to play with and why and they also know why they already exclude and already attack those that they do not like (Rebolo Marques et al, 2014).

Bibliographic references

I. Angulo, J. C.; Neto, C. & Ortega, R. (2001). Questionário de nomeação de pares. FMH UTL, non-published document

II. Boulton, M. J. (1995). Patterns of bully/victim problems in mixed race groups of children. Social Development, 4, 277-293

III. Boulton, M. J. & Smith, P. K. (1994). Bully/victim problems in middle-school children: Stability, self-perceived competence, peer perceptions and peer acceptance. British Journal of Developmental Psychology, 12, 315-329

IV. Cerezo Ramirez, F. (2001). Condutas agressivas na idade escolar. Lisboa: McGraw-Hill

V. Coie, J. D. & Dodge, K. A. (1988). Multiple sources of data on social behavior and social status in the school: A cross-age comparison. Child Development, 59, 815-829

VI. Hymel, S., Vaillancourt, T., McDougall, P. & Renshaaw, P. D. (2004). Peer acceptance and rejection in childhood. In P. K. Smith & C. H. Hart (Eds.) Blakwell handbook of childhood social development (pp. 265-284). Malden, Oxford, Victoria: Blakwell Publishing.

VII. Ladd, G. W. & Price, J. M. (1993). Playstyles of peer-accepted and peer-rejected children on the playground. In C. H. Hart (Ed.) Children on playgrounds: Research perspectives and applications (pp.130-161). Albany: SUNY.Ladd (1983)

VIII. Melin, F. (2011). Na escola: és feliz? Dissertação de Doutoramento. Braga: Universidade do Minho

IX. Newman, B. & Newman, P. (1991). Development through life - A psychosocial approach (Fifth Edition). California: Brooks/Cole Publishing Company

X. Olweus, D. (1993). Bullying at school - What we know and what we can do, Oxford UK & Cambridge USA: Blackwell

XI. Parker, J. G. & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low accepted children at risk?. Psychological Bulletin, 102, 3, 357-389

XII. Pereira, B. O. (2002). Para uma escola sem violência: Estudo e prevenção das práticas agressivas entre crianças, Porto: Fundação Calouste Gulbenkian, Fundação para a Ciência e a tecnologia.

XIII. Rebolo Marques, A. (2006). Jogo de luta e bullying no recreio escolar, dissertação de doutoramento, FMH-UTL

XIV. Rebolo Marques, A. (2016). Vivências de bullying e risco de insucesso escolar. In Beatriz Pereira, Altemir José Gonçalves Barbosa, Lélio Moura Lourenço (Organizadores) Estudos sobre bullying: família, escola e atores, Curitiba-Brasil: Editora CRV

XV. Rebolo-Marques, A.; Ferreira, A.; Campos, A.P.; Valente, A.; Sousa, A.; Silva, C.; Carvalho, F.; Miranda, K.; Alves, L.; Leitão, R.; Pólvora, S. (2014). Brincar e cooperar para o bullying evitar, in Carlos Neto, Jão Barreiros, Rita Cordovil, Filipe Melo (eds.) Estudos em Desenvolvimento Motor da Criança VII, Cruz Quebrada: FMH, pp. 221-226

XVI. Saraiva, A. B.; Pereira, B. & Zamith-Cruz, J. M. (2011). Trajetórias, vidas e bullying escolar, in Altemir Gonçalves Barbosa, Lélio Moura Lourenço & Beatriz Pereira (organizadores) Bullying, conhecer e intervir, Juiz de Fora: Editora UFJF

XVII. Serbin, L. A., Marchessault, K., Mcaffer, V., Peters, P. & Schwartzman, A. E. (1993). Patterns of social behavior on the playground in 9- to 11-year-old girls and boys: Relation to teacher perceptions and to peer ratings of aggression, withdrawal and likability. In C. H. Hart (Ed.) Children on playgrounds: Research perspectives and applications (pp. p.162-183). Albany: SUNY.

XVIII. Sharp, S. & Smith, P. K. (1994). Understanding bullying. In S. Sharp & P. Smith (Eds.), Tackling bullying in your school, A pratical handbook for teachers. (pp. 1-6). London & New York: Routledge.

XIX. Smith, P. K., Cowie, H. & Berdondini, L. (1994). Co-operation and bullying. In P. Kutchnick & C. Rodgers (Eds.) Groups in schools, London & Mew York: Cassel Education, 195- 210

XX. Whitney, I. & Smith, P. K. (1993). A survey of the nature and extent of bullying in junior/middle and secondary schools. Educational Research, vol. 35, 1, 3-25

Structuring a Music-Based Program for At-Risk Children

Ivana Pinho Kuhn

Supervisor Director, CSSL - Child Singing and Language Learning Project (Germany)

Abstract:

Music-based non-profit programs for children at risk created in recent years have the common goal of providing music education as a tool to promote social change. Pre-existing curriculum models conceived for regular classroom, or adopted from other music-based social programs, bypass individual and relevant factors that reflect the needs of distinct groups. This explanatory study discusses the structuring of a music-based preventive program with a social project developed by a non-profit private foundation. Analysis of this case study shows consistent attention towards a theoretical construct that defines the pedagogical strategy adopted in the program. The study demonstrates the impact an arts afterschool project had on children’s educational and social engagements. Pedagogical principles and learning strategies discussed here offer basic insights that can assist similar socio-music initiatives.

Keywords: music education, social pedagogy, at-risk children, prevention, after-school programs.

Introduction

The proposal for an educational social initiative reflects multifaceted tasks related to interdisciplinary pedagogical approaches that are based on philosophical and educational principles across various disciplines (Chen-Hafteck, 2016; Lindblom, 2016; Reschke-Hernández, 2011; Zigo, 2011; Kuhn, 2013; Oliveira, 2003; Oliveira & Harder, 2008; Chrysostomou, 2004; Dillon, 2006; Cunningham et al., 1995). Music-based social initiatives have turned into an alternative form of complimentary education, which has been proven to be beneficial to a growing population of children in need living in impoverished urban areas (Stevenson et al., 2013). In recent years, private and non-profit organizations have been offering support to social projects as part of recovery initiatives to help children at risk. Social programs based on arts have the potential to involve children and communities in a cooperative learning and social process that unfold emotional awareness. The positive prospects of an educational program rely on the choice of a comprehensive didactic that fosters creativity and help children exercise the learned skills with self-confidence. The work developed in arts-based social projects can become a motivating factor in learning of acquired skills with emotional expression, and consequently serve as an interventive action for children and youth. Music education programs for at-risk children require pedagogues to have good command and preparation to teach this subject area with a willingness to assume a flexible and reflective teaching strategy that observes students’ exceptional needs. In 2008, Oliveira & Harder suggested that music education is effective when pedagogues implement a teaching practice centered on the acceptance of student’s ideas, origins, language, culture, and interests. This principle applies to both formal and informal educational settings and calls teachers to act on behalf of children. In music-based projects, the development of a positive interaction between pedagogue and pupil depends on the levels of response and interests the learning experience awaken in joined activities.

The challenges pedagogues encounter to structure a music social program are reflected in the complexity of a curriculum and practice that entail flexibility and creativity in its basic concept and early implementation. Music-based social programs follow unique constructs that include tolerance and acceptance including needed teaching assessment. A clear teaching strategy encourages collaboration, participation, group interaction, social awareness, and learning. Music activities stimulate children’s ability to express themselves and acknowledge the importance of their contribution. Therefore, art pedagogues are expected to pursue a teaching philosophy that values teamwork within a process of individual achievement.

Related studies have raised attention to the positive results and effects that arts-based programs have on children that are at risk of marginalization (Lindblom, 2016; Coholic & Cadell, 2009; Bittman et al., 2005; Oliveira, 2003; Badry et al., 2002). However, little attention has been given to the pedagogical framework that defines the construct of these type of initiatives. In a socio-educational program that is conceived as an outreach resource for children at risk, music functions as a major source for learning and social interactivity. Therefore, this investigation offers an analysis of a relevant case study seeking to expose a possible theoretical basis and pedagogical practices applicable to a social music initiative for children and youth of low-income families living under critical circumstances in urban areas.

Children at risk

The 2016 report delivered by the UNICEF shows that many of the social challenges of the 21st century, including civil war, globalization, migration, overpopulation, violence, and extreme poverty, have been depriving millions of children of basic human rights, and therefore from a prospective future. Children are susceptible to hardships when going through troubled situations and conflicts in their environment. In immediate interactive social circles, which include family, peers, and their community, many children are exposed to violence and traumatic events leading to dramatic changes that affect their living conditions. The consequences of living in unstable and unsafe environments during infancy and puberty make children vulnerable to social exclusion and marginalization, physically abused, sexual exploitation, and in many cases slavery. The impact of family and community’s violence on children and youth’s well-being have immediate socio-emotional and physical consequences that will determine later outcomes in adulthood (Marteleto et al., 2016; Cantor, 2016; Larkin et al., 2014; Reiss, 2013; Kennedy et al., 2010; Margolin & Gordis, 2000). The 2016 UNICEF State of the World's Children Report indicates that in our time 250 million children live in countries affected by conflicts, 39 million children are forcibly displaced, and 500 million children are at risk of being affected by environmental disasters. These statistics show that many minors under the age of 18 years are in danger of not reaching adulthood and to perish under conditions of poor physical and mental health, aggravated by the lack of decent living conditions, emotional support, and basic education.

The quality and levels of social interactions children experience with family, peers, and community are key factors to be observed in a proposed intervention or prevention program that targets children at risk (Shire, 2016; January et al., 2016). In an unsafe home environment, children and adolescents are more vulnerable and susceptible to develop psychological disorders that seriously disrupt a normal development, thus compromising future physical, socio-intellectual abilities (Marteleto et al., 2016; Chan &, 2013; Margolin & Gordis, 2000). During puberty, adolescents often find themselves in situations that challenge their ability to deal with problems. Positive relationships established in childhood and adolescence reinforce emotional stability and intellectual development, helping the child to strive academically and to build values that are relevant for their self-confidence and social behavior (Card & Little 2006). Positive interactions between children, family, community, and peers help establish a favorable home environment in which children can pursue their best potentials and counterweight their emotional and social development (Matens & Coatsworth, 1998).

In recent decades, a rising number of armed and extremely violent conflicts worldwide have brought devastating consequences to vulnerable children and their communities. Left only with limited options, stay in embattled areas or flee their habitat and become refugees, children from combat zones are confronted with strenuous living conditions and extreme violence. Through the work of non-profit and private organizations, caregivers, pedagogues, psychologists, medical doctors, and social workers have reached millions of children at risk. An increasing number of socio-educational initiatives have been created aiming to encourage school retention and learning of applied skills, especially assisting children that have been forcibly displaced and struggle in a hostile social environment that poses threats of marginalization and violence. Pedagogues agree, however, that vulnerable groups of children living under the poverty line require intervention strategies that reach to children in their related community and family settings (Reiss, 2013; Heckman et al., 2013; Larkin et al., 2014). For children and youth settled in impoverished communities around urban areas, there are often barriers that prevent them to pursue an education and to remain and strive in school. Pedagogues working with at-risk children in a formal classroom setting or in an informal educational program have a significant influence on the child’s welfare. By assuming the role of a learning mediator, teachers can provide socio-educational support and encourage learning and development in a challenging living context (Úcar, 2013; Freire, 1997).

Socio-educational music initiatives for at-risk children

Pedagogues agree that childhood learning experiences and early social interaction in both non-educational and educational contexts are relevant to the emotional development of children, and have an impact on later choices they make in adulthood (Sims, & Waniganayake, 2015; Blatchford et al., 2015; Úcar, 2013). In the 1980’s, a surge of music-based programs drove attention towards the benefits of music education to at-risk children. In Latin America, the children’s music orchestral project entitled El Sistema, and in Africa, the singing groups from the non-profit organization African Children’s Choir. represented some of the best initiatives that inspired other similar music education and social actions developed in recent decades (Kuhn, 2013).

In addition to international humanitarian programs, the work of socio-educational endeavors, undertaken by private non-profit organizations in recent years, has been providing early intervention, preventive actions, and substantial support to children of various needed communities (Defourny & Nissens, 2001). Among the various types of social projects implemented worldwide are those created with the purpose of offering additional educational activities to support children to remain in schools. Extra-curricular music activities also target general learning through collaborative activities that deliver social, educational, and emotional assistance to minors at risk. However, only programs with a strong pedagogical foundation appear capable of delivering immediate assistance with a long-lasting positive impact. Learning engagement with consistent social goals can turn a learning experience into a life-changing opportunity for children, their families, and communities.

Music programs implemented as an after-school activity in partnership with schools and community outreach organizations have given children access to further educational opportunities (Hodges & O’Connell, 2005). For children victims of violence and abuse, the opportunity to take part in a music outreach program provides both educational and therapeutic benefits (Crenshaw & Hardy, 2007; Green, 2011). Research has shown that engagement in music and arts activities strengthens the child’s self-esteem and ability to deal with critical issues at home and school environments (Coholic et al., 2009; Kuhn, 2013). Therefore, engagement in music lessons can well serve as a tool in programs of prevention and intervention aimed to benefit children in need (Kelly & Doherty, 2016). In arts-based activities, children and community share experiences that contribute to their relationship and perception of one another. In 2007, in a unique partnership, the Seattle theater, that city police department, schools, and community organizations in the United States started a music project entitled the West Side Story Project (WSSP). An arts program developed with the goal of implementing new policies and promote social services of violence prevention to adolescents, the WSSP combined artistic components of acting, dance, and sing, using the Bernstein’s musical play as a medium for participants to express and work their feelings. The positive results of the WSSP city-wide summits led to the development of a broader nationwide program with similar initiatives.

Interaction and collaboration in socio-pedagogical music projects involving children at risk are essential motivational components that unfold an intricated emotional and intellectual thread with the aid of art expression. Teaching strategies, methods, and theoretical basis adopted in an informal music program constitute the core of a socio-pedagogical praxis. The curriculum model set for regular school music education classes complies with a year-long framework associated with learning stages in an upper-grade system. This type of curriculum concept restricts the possibilities of adopting a more flexible and adaptable teaching approach to suit at-risk children’s groups. The construct of a music-based program of prevention calls for theoretical and teaching principles that enable pedagogues to meet socio-emotional demands within a constructive and supportive learning environment involving children, their family, and community.

Theoretical fundaments of a music-based social program

Music classes with social intervention goals require a consistent and interdisciplinary pedagogical didactic. A teaching expertise and knowledge in areas of social pedagogy and music education provide the solid fundament for an educational practice that aims to transform both teacher and pupil in a joining process. The pedagogical principles that define a social music action expose a theoretical foundation laid on an interdisciplinary approach. In the context of social music projects, the educator plays a key role in providing a life-changing learning experience that enhances children’s ability to handle challenges inside and outside the learning environment. The essence of pedagogical principles that suit a music-based undertake for children at risk relies on teachers’ ability to establish his or her own individual teaching philosophy. The task of teaching music to children, who otherwise would have no financial means to afford music lessons and are on the verge of school dropout and marginalization, is key to the development of a pedagogical approach that put together knowledge and expertise in such a unique classroom situation. A mutual collaboration in shared learning experiences has the potential to create a trustful and respectful exchange of knowledge. Pedagogues involved in social art projects face challenging tasks that include readiness in demonstrating the capacity of using self-critical skills, ability to assess and bend their teaching strategies to alternative approaches if needed, in a reciprocal manner that allow an educational dialogue in a continuous learning process fond on mutual trust (Oliveira, 2016).

In the proposed social pedagogical approach presented by Badry (Badry et al., 2002), learning occurs as part of a natural interactive process in which teacher and pupils undertake a common project and work together towards its completion, thus sharing a reciprocal interest in the subject. For the music pedagogue assuming an authentic and self-reflective position, teaching and learning turn into a valuable mutual learning experience. A three-ends proposed approach for a music-based curriculum bond the pedagogue, the child, and music as a subject of common interest. A positive connection between pupil and educator in a common activity determines the quality of an interactive learning experience. Music activities used in social pedagogical practices build and strengthen trust and respect between pedagogues and children in a process that also unveils new aptitudes in face of common challenges. The essence of teaching and learning experiences in common shared activities has reciprocal ties that stress the significance of cooperation in the learning process. A social pedagogical approach based on music as a third and common element of mutual interest places teachers and pupils on equal terms of collaboration, in an environment, that demands joint efforts to conclude the sought activity. A completed task means accomplishment and rewards for teachers and students alike.

The content of a music and social proposal needs to address teaching practices that nurture an engaging and motivational learning environment. Sociocultural elements function as self-identification factors that help children recognize themselves in the learning process with confidence to freely express themselves. In discussing teacher education, Oliveira (2016) proposes a sociocultural music teaching approach that is positive, relying on observation and natural techniques to encourage expression with sensibility and attention to student’s needs. From this perspective, an informal teaching approach allows more time and opportunities for interactivity, making it possible for educators to transfer their knowledge and skills from regular teaching to contexts of informal and out-of-school education. The emphasis on a creative didact, which differs in timing and structure from music classes prepared for a regular school classroom, expands student’s music experience to beyond curricular boundaries and unveils new dimensions in teaching-learning interaction (Kuhn et al., 2010). Pupil’s music preferences and practices involving singing, playing, dance or listening to various styles fit the needs of educational resources to be explored in an informal music teaching plan.

Music learning in early childhood is an exploratory experience that seeks to introduce sounds as a meaningful medium of communication. In their early years, children experiment and respond to music in a variety of ways in a free and creative manner. Whether exploring instrument playing, listening, physical movement, singing, or simply enjoying surround music, all children in their early stages of development are deeply affected by sounds. Young children tend to learn music as part of a natural process following a common tactic based on listening, imitation, and repetition. Music education methodologies applied to formal classroom settings can be considered for informal education scenarios after implementation of alternative and flexible teaching strategies. Far from improvised, however, teaching models for the informal instruction of young at-risk children in outside school activities have additional demands to be met by educators. A social perspective and broad knowledge of the subject, and good command of combined teaching methodologies are relevant to the development of strategies that suit all phases of a social arts program.

Music methods commonly used in general music education – e.g. Orff, Kodaly, and Dalcroze - can be adopted in music activities across various age groups, and included in informal educational learning involving groups of at-risk children. Group teaching approaches applied to large singing or instrumental ensembles are often associated with some music-based projects set on basis of a socio-educational principle. Educational proposals involving children and adolescents at risk in impoverished communities worldwide have focused mostly on group activities. Considering this, music group teaching methodologies applied to regular music education observe the correspondent phases of pupil’s age and learning levels. Music education methods based on Kodaly and Orff approaches fit group classes with activities meant for beginners at primary school level. Often applied in preschool settings, the Orff music method involves children in group activities led by one or more teachers or caregivers. The instruments designed for the Orff method are small-size variations of xylophone, metallophones, flute, shakers, tambourine and other percussion instruments designed for preschool children. Music teaching methods for young children introduce sometimes basic elements of music notation through singing and playing. The vocal expression has physical, cognitive, emotional and social significance in early childhood. Solfege is a music singing technique used to teach singing of melodies with correspondent music notes using syllables - e.g. do, re, mi, fa, sol, la, si – instead of lyrics. Kodaly solfege applies a technique known as fixed do in which children respond to teacher’s hand gestures singing improvised melodies guided by the instructor. Teacher and student’s interactivity in this type of vocal learning result in a collaborative approach. The Kodaly solfege system helps enhance vocal skills with attention to cultural elements by focusing on popular repertoires of folk melodies. Children’s responses to music with body movements are explored in an approach referred to as Eurhythmics. The Dalcroze Eurhythmics approach engages pupils and educators in improvisational moves in both individual and collective experiences of music audio perception and physical expressiveness. Music programs adopting Dalcroze Eurhythmics aim to develop music awareness based on group learning exercises involving cognitive, physical, and social skills through collaborative action. Learning to play a musical instrument requires the child to build individual discipline, and to keep with regular practice, attendance and participation in the lessons. Once mastering a level, students are presented with new learning challenges and increasingly demanding technique. Studies have shown that early music learning has a positive impact on children’s development and social interaction and encourages participation, collaboration, and communication with emphasis on creativity and self-expression (D’Ausilio, 2015; Bolduc, 2008). In music-based social actions presented as an after-school activity, teachers’ choice of music education methods, as those described here, and social-pedagogical strategies eventually determine the outcomes of the project.

Case Study

This explanatory study discusses the framework set for a prevention program based on music education, aimed to benefit a group population of children in Latin America at risk of leaving school and fallen into marginalization. The AmiMusik project, undertaken by a private foundation in Colombia, started offering an after-school program with music activities for children living in displaced communities. After fleeing their homes in rural areas due to warfare, these communities relocated to suburban areas around the capital Bogota. The case study focuses on the structuring of the music-based project sought to contribute to school retention of displace children, and prevent youth marginalization. Data provided by the United Nations show the extensive damage of the long-lasting civil war in that South American country, with more than 150,000 deaths of civilians, among them around 45,000 children, and the disappearance of 8,000 minors forced to join the guerrillas or killed in the fight. The aftermath of this recently ended conflict left communities destroyed and children and their families migrating to major urban cities. The hardships children face in such circumstances make them vulnerable and exposed to perils of marginalization. The project observed that impoverishment and socio-emotional factors demotivate and prevent children from engaging in a regular school education. The social project offered educational benefits to children living in these displaced communities that were not part of their regular school curriculum. The number of children not attending and dropping out of school in that city in recent years has led organizations to implement educational projects focusing on preventive measures to avoid marginalization. The risk that children and adolescents join gangs and criminal illegal groups is very high for children of displaced families. The families reported many cases of their own in their young population. Participation in group music activities offered by social educational projects like the one discussed here has surged as an alternative and appealing call to children and their communities. Music social projects targeting healthy and positive human collaboration through arts engaging activities have offered positive results. The case study of this arts-based intervention program examines how its reach extends to students in all their educational environments based on the pedagogical music approach developed for the project.

The construct of a curriculum framework and teaching concept of a music-based initiative of long-term benefits analyzed in this case study raises important questions that concern the pedagogical core of a preventive action: (1) what is the structure of a pedagogical didactic and practice in a music education social program? (2) why do arts in social initiatives require a unique learning approach? (3) what is the theoretical basis of a music education praxis outside the regular classroom?

In the initial phase of the project, the pedagogical team established a communication channel with targeted communities with regular visits to the neighborhoods and families taking part in the project. The pedagogical team of the project informed the communities information about the music program and explained the need for parents’ permission for their children to participate in the project and join the music after-school activities. The results obtained from interviews conducted with parents and children served as a reference to identify the educational needs of those to be involved in the project and to create a correspondent pedagogical didactic for the program. Based on the available resources, the project served an initial number of 112 students ages between 5 and 14 years old. A total of four music teachers were responsible for various group music activities, in which participating children were grouped according to their age levels. The pedagogical team included a social worker, music pedagogues, an ethics expert, and a legal assistant. Meetings occurred three times a week during the after-school period, and children and educators interacted in group activities involving music playing, listening, movement, singing, and improvisation. The support team of academic advisors including specialists in music education, social work, and ethics, developed an interdisciplinary pedagogical guide for teachers. Additional teacher training was provided prior to the project’s implementation and included seminars, workshops, and team discussions.

The task of assembling a program with an interdisciplinary approach posed many challenges to teachers. The pedagogical guide, seminars, workshops and group discussions solved educational issues addressed by the teachers along the program initial phase. The interdisciplinary approach involving music and social activities required combined support from the specialists. The goal of this preparatory stage was to develop teachers’ skills in building an informal music learning experience within a shared learning context. Teachers moved from the role of passive observers to an active participant to interact with students during all music activities. Upon the conclusion of the project’s first-year implementation, students offered a public performance to their families and communities that summarized the learned music skills they acquired with the assistance of the teachers. The performance was part of the strategy used to include families and communities in the final part of the program. School retention of participant children with regular attendance monitored by parents and reported to the program’s team was recorded during the one-year program.

Discussion

This case study discusses the structuring of a music-based program and social project based on a teaching and learning concept that engages children at risk in activities that support their social, emotional, and intellectual development. The structure of a consistent pedagogical didactic and practice adopted in a music education social program depends on careful considerations taken prior to the implementation of the project. A teaching approach in arts-based social initiatives involves theory and praxis related to educational and social disciplines to consolidate an effective program. The preparation of music teachers to work with children at risk in non-formal learning settings has a decisive influence on the outcomes of a music-based social project.

Unlike other social programs that promote schooling or general activities for underserved children, arts initiatives deliver learning of applied skills that engage the child in expressing themselves with creativity, thus breaking with emotional and social barriers. The music apprenticeship in socio-educational projects has long-lasting effects and deep significance for children, affecting the way they perceive themselves as part of a special community that promotes art as a positive experience. In the project described in this case study, a compromise among pedagogues, children, and families to keep with attendance in a regular school, served as an encouragement and was a condition for children wishing to remain in the program. The pedagogical guide developed for the music program addressed in this study reveals the project’s close partnership with school, families, and communities, and the attention of the pedagogical committee towards activities that called for group collaboration. Adopting a three-dimensional curriculum approach based on the teaching concept of shared learning, the music-based proposal summarized key components in social pedagogy, music education, and philosophical principles to consolidate a didactic of cooperative knowledge. The teaching concept proposed in the pedagogical guide (Fig.1), connects these three areas of expertise and summarizes a participative didactic that allowed students to bring their share of contribution to the learning process.

Fig. 1. The pedagogical concept of a music-based social program.

Music making offers an engaging opportunity for students to apply learned skills and knowledge in a group experience with socio-emotional involvement. Therefore, the meaning of music activities offered in a socio-educational program for at-risk children relies greatly on the positive experience and level of interaction pedagogues and the program establish with pupils and their families and communities through collaborative work. A music listening experience represents an individual way of learning and acknowledgment of individual emotional and social responses. Other music activities offered in the project discussed in the case study, e.g. singing, playing, and improvisation, assisted teachers and students to demonstrate the significance of teamwork to accomplish a learning goal.

Conclusion

The analysis of the case study suggests that the structuring of a music-based initiative for children at risk involves the planning and development of a comprehensive pedagogical construct. The positive outcome of a socio-educational endeavor relies on the level of interaction established between pedagogue and pupils. Hence, the concept of an appropriate didactic with a theoretical fundament that sustains a music education and social pedagogy praxis enables educators to work within an interdisciplinary approach applying a multidimensional pedagogical curriculum framework. An interdisciplinary teaching philosophy sustains an education that supports children and nurtures a productive learning environment. The construct of a music-based program has a broad reach to distinct pedagogical fields that are consistent with the idea of learning through collaborative artistic expression on equal levels of participation. The pedagogical concept discussed in the case study represents an example that can assist pedagogues in the development of a sensible teaching philosophy towards at-risk students. A comprehensive teaching philosophy empowers pedagogues to support children and adolescents to gain confidence in themselves and to continue building their strength through education. Music-based projects have been used as an effective tool of intervention and prevention for children and adolescents in need, and these projects can further serve the purpose of encouraging school retention and stimulating academic achievement as shown in this study. Additional studies and analysis of other similar cases are strongly recommended to expand the possibilities of alternative educational approaches that effectively support at-risk children in non-formal educational settings.

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EPR's Paradox: Reading “The Einstein's Paradox and other Science Mysteries Solved by Sherlock Holmes”

Maira Lavalhegas Hallack

University Center of Medical Science at Abc

Maria Cristina Lavalhegas

University Center of Medical Science at Abc;

Linda Cochrane

Concordia University

Abstract

This research paper is part of a study which looks into the possibility of using readings from the Brazilian edition of “The Einstein's Paradox and Other Science Mysteries Solved by Sherlock Holmes” as a means to promote an understanding of Einstein, Podolsky and Rosen's Paradox for use in teaching physics. Understanding physics as culture, as a relation between humans and reality, we defend the introduction of a different discourse as part of a methodology for teaching physics. Also, for us, it is important that teachers be open to the use of such readings independent of his subject. Because of that, we propose to understand how the discourse of the Brazilian edition of the book is built using the French analysis of discourse, which has one of its foundation is Michel Pêcheux, and, in addition, some of ideas promoted by Eni Orlandi. For our analysis, we took the original articles of Niels Bohr and of A. Einstein, B. Podolsky and N. Rosen. Then, we thought about how the fictional stories used such concepts as: “criterion of reality”, “complementarity”, “probability wave”, “entangled” and “particle's no-space”, Einstein, Podolsky and Rosen proposed them and Bohr argued about them. Although, the fiction writer broached both ideas, he did not present both sides of the discussion.

Keywords: Paradox of Einstein, Podolsky and Rosen, reading, “The Einstein's Paradox and other Science Mysteries solved by Sherlock Holmes”

Introduction

Research into the teaching of science has demonstrated the importance of in-class reading. Some examples of such research are: Almeida e Ricon (1993), which discusses the possibility of reading, in physics classes, science popularization texts and novels; and Nascimento e Rezende (2010) which gives a broad bibliographic review of the use of science popularization texts in the teaching of science. Both of these reaffirm the importance of the use such texts as part of a pedagogic methodology. We emphasize the importance of such reading because of how it contributes to the citizen formation of students. The readings should be more than a language or literature class, as Cassiani (2012) affirms, since the difference in context enables different interpretations. (ORLANDI, 2001).

Using the preceding, we propose to analyze the book “The Einstein's Paradox and other Science Mysteries solved by Sherlock Holmes” (2002) by the physicist Colin Bruce — a “science spreader”, as he calls himself. The topic of his book is the paradox presented by Einstein, Podolsky and Rosen (EPR). This topic, as Michel Paty (2003) shows, is polemic but its philosophical viewpoint is often assumed to have only a mathematical meaning. Then, the writer provides a Quantum Mechanics (QM) interpretation.

Since its creation, quantum mechanics has raised “interpretation” problems, which quickly has formatted like philosophic discuss about the knowledge and the reality. At the same time, it allowed describe and pre-said the atomic phenomenon and radiation the quantum mechanics seemed to show limitations in relation to canons of the firstly physic knowledge: probabilistic description, (…) “indeterminate” relation (…), complementarity of dual description in wave function and particles way and the conjugate measure (…) at the place of only one description (…)* (IDEM, p.71)

There is no consensus about this theme, though the orthodox interpretation, or the Copenhagen Interpretation, has been predominant because of certain experiments such as Alain Aspect’s experiment in the 1960’s which is an adaptation of Erwin Schrödinger cat experiment for practical laboratory analyses that corroborates QM theoretical results.

On the other hand, this theory is contrary to epistemic principles of Classical Physics (CP),

(…) The Quantum theory seemed, then, to open a new kind of physic theory: it consists of abstract formalism added of a physic interpretation its elements, while, in the physic theory primarily the mathematics mode of measure were directly organized for the constitution of theoretical relations that gave the “physic content”. In any way, the mathematics expression of measure and the relation between them (equations) were directly related to the physic meaning of this measure.* (IBIDEM, p.75)

Physics is not only mathematical formalism, although the former is contemplated in the latter. The first depends on the “interpretation”, which is based and bases itself on mathematical formalism. Some physicists defend the QM interpretation when they understand subatomic particles as ensemble of auto valor and autovector functions.

In summary,

The question and the status abstract, the own concepts and quantum measure, of that, we highlight the importance about it says in respect of physic interpretation, it concerns of interpretation philosophic view (…) and it was set on second plan* (IBIDEM, p.77)

The importance of this work in the field of science teaching is affirmed by the proposals of Almeida and Sorpreso (2011) in “Analytical device for reading comprehension of different kinds of texts: examples about Physics”, which

(...) we do not read as the same way the didactic book, the Science popularization texts or scientist primal, due to this reading mobilize different inter-speech, even that is made by the same person, once that assume different memory about its production (…)* (IDEM, p. 84)

Moreover, we reiterate

Detail any dispositive of this type is explained by the fact of that, even we emphasize in the reading possible interpretation of different kind of texts (…) mobilize different inter-speech, we are contributed to rethink about the use of textual type in teaching situation.* (IBIDEM, p. 84)

This work defends the use of different kinds of text which have “(...) different direction of producer (…) and ways as usually are used (…) We can say in the everyday life of people; these texts work the same way.” (IBIDEM, p. 84). Each kind of text has a different target and ideal reader, for whom the writer writes. On the other hand, there is an ideal writer with whom the real reader enters into a dialogue.

Through reading, there is a possibility of introducing modern and contemporary physics in class. This enables students to be autonomous in their view of reality and also allows schoolchildren, who are not adept in mathematical language, to involve learning physics. However, the important introduction of the texts in class, the usual and mathematics language cannot be super position.

Teaching physics is performed by a dialogue between both literary and scientific language. For this reason, the significance of the proposed readings should be introduced in addition to and not instead of the mathematical language. Physics classes should allow students to become acquainted with physics while also being introduced to the culture, as Zanetic (1989), rather than as mere training in the solution the exercise problems.

Although a significant amount of research defends the importance of such readings in science and mathematics classes, Bertoldo et al (2014) showed that few teachers use it in their classes. Most physics classes can be summarized as repetitive reading whereby students only copy down examples of exercise solutions, of empiric copies. (ORLANDI, 1996).

This study is part of a master’s research, which has been performed since 2015 and engaged different collaborations, moreover, the researchers of Science Teaching (gePce) of Education Faculty (FE) at State University of Campinas (UNICAMP) and relied on the support of high school students and teachers.

Based on this, we try to perform a Discourse Analysis constructed by Colin Bruce (2002) on the EPR Paradox. We show how the book’s discourse is built around a discussion marked by Albert Einstein and Niels Bohr, on the completion of the QM interpretation described in the EPR paper. Therefore, we researched more papers, which were the basis of the discussion, such as Niels Bohr (1958).

This last writer explained the difference between the philosophical principle of CP and QM. He affirmed that CP is based on epistemological determinism. On the other hand, QM is seen from the viewpoint of probabilistic auto value, of proposition complementarity, of particle nonlocality and the uncertain measurement between two pairs of observables, for example, energy and time or position and momentum:

The whole approach is not only in complete accordance with the usual chemical kinetics, but even stresses the simple assumptions on which it is based. Thus, in any process resulting in chemical combinations,the properties of the new molecules do not primarily depend on the composition of the molecules by whose interaction they were formed, but only on the relative placing of the atoms of which they consist. Any secondary characteristics of the state of such molecules, corresponding to oscillations left from their formation, will indeed not essentially affect their chemical properties and will even, due to the general thermal agitations in the medium, rapidly lose all connection with their previous history. (…)

A new epoch in physical science was inaugurated, however, by Planck's discovery of the elementary quantum of action, which revealed a feature of wholeness inherent in atomic processes, going far beyond the ancient idea of the limited divisibility of matter. Indeed, it became clear that the pictorial description of classical physical theories represents an idealization valid only for phenomena in the analysis of which all actions involved are sufficiently large to permit the neglect of the quantum. While this condition is amply fulfilled in phenomena on the ordinary scale, we meet in experimental evidence concerning atomic particles with regularities of a novel type, incompatible with deterministic analysis. These quantal laws determine the peculiar stability and reactions of atomic systems, and are thus ultimately responsible for the properties of matter on which our means of observation depend** (p.19-20)

The QM interpretation broke with the scientific way of doing CP. According to Bohr (1958), although the scientific logic of QM changed that of CP, the desire to enrich knowledge, of the harmony and beauty of physics are not abandoned, only how it’s done is summarized differently, because the old logic is not enough to explain both the ‘quantum’ and other key concepts of the atomic world.The book, which we analyze here, like Bruce’s old texts, even though the writer is a physicist by degree, has written for the layperson in physics – his contribution -- his aim has been to simplify this science. As for the narrative of his book, the idea of writing for the layperson is evidenced by Dr. Watson’s character, a doctor, a layperson in the science of physics, contrary to the characters of detective Sherlock Holmes and other scientists, who help solve the police and scientific case.

- It let me extremally disturbed, Holmes, I said. I scarcely was begging to understand how the physics scientist comprehend the universe in terms of specific quantities, which are always tightly conserved. Now you are telling me a complete paradox, in this, some energy can grow from anywhere and the elements can become in each other.* (BRUCE, 2002, p. 79)

Another sign of Dr. Watson’s ignorance is when one of the scientists affirms that he will use as little mathematics as possible so that Dr. Watson and Sherlock could understand the phenomenon.

Challenger set up. – Ah, but after the third step has been coming, high level of the scientific understanding, in the qualitive interpretation, it is both difficult and essentially important, he said. Usually, it is necessary firstly to get the math without doubt. However, we guess I can explain the topic in way, specially, you will be able to get the third stage of true wisdom without to pass all bored step. I will explain in way to be clear the question will be obvious for a dumb. *(IDEM, p. 122)

The book is composed of short stories, each chapter is independent and they describe different police cases as science develops. Moreover, it references a classic literature detective created by Sir Arthur Conan Doyle (1887 – 1927). Nowadays, there are many movies and series based on Doyle’s stories.

Initiating a scientific research internship involving a class in High School, which allowed us to observe the popularization of Doyle’s detective and mystery stories, bringing the students closer to reading the excerpt of Bruce’s (2012) book, “The Einstein's Paradox and other Science Mysteries solved by Sherlock Holmes”, through an interpretation and representation exercise on their reading and previous knowledge (reading memories).

In this article, we tried to understand how the discourse in Bruce (2002) - as the author is popularizer and admirer of science – elaborates the notion of the EPR Paradox, which involves epistemological knowledge of physics .

Thus, according to our goal and in agreement with Bohr (1958) on the importance of language in the teaching process, we tried to find a methodological-theoretical support which allows us to analyze the process. We have proposed to consider the nontransparency of language and all discourses are built with new meanings being produced, the said and unsaid, the relationship between writer and reader.

Thus, we support our ideas with some notions established in this trend by Eni Orlandi (1983, 1996, 2001, 2012) in view of discourse analysis (DA), which began in France with Michel Pêcheux. We use some notions of this trend, such as discursive formation, the relation between format and content, nontransparency of language, the meaning produced by discursive relations, the polysemy of language and the condition of immediate and socio-historical production.

Theoretical–Methodological Support.

We have used as theoretical methodological support some notions of DA, of the French trend, which had Michel Pêcheux as one of its founders and we were especially guided by Eni Orlandi’s research. Based on this support, we tried to understand Bruce’s (2002) discourse. In addition to DA, we have made use of some notions of the Science Teaching (ST) field, which we can use to explain the importance of understanding a book that discusses some scientific notions using ST narratives.

We used the scientific view of culture (ZANETIC, 1989); the book as class content, understanding this as class totality, not only as a motivator (PIASSI, 2013); but reading as a didactic strategy (ALMEIDA & MOZENA, 200; ALMEIDA 2004 e 2013; CASSIANI & GERALDI, 2012) and the importance of the teacher as a mediator. (ZYBERSTAJN, 1984).

According to our methodological and theoretical support, this allows us to understand how meaning is produced. The process by which this occurs depends on the condition of this process, elaborated by the writer, for that it is necessary to understand the relationship between language and the subject’s exterior, which is a result of the producer’s conduction of meaning, this being immediate; and the socio-historical context. (ORLANDI, 1983).

Meaning is neither defined by a person’s speech, nor do worlds have meaning. These are built into immediate situational reading memory, socio-historical context and the relationship between interlocutors. Therefore, there is not only one aspect relating language, world and thought. Neither is language a transmission of pre-meaning, because our relationship with our exterior changes each person’s production of meaning. (ORLANDI, 2005).

DA’s main notion is that language is not transparent, the discourse is built by meaning’s effects between interlocutors. All kinds of discourse are had “(…) the mechanism of all the rules of social formation of projection which is determined by the situation of the concretes and the representation of this situation within discourse.” (ORLANDI, 1983, p. 9)

The pre-meaning as “literal sense”, because of that in some determined condition, there is a dominant production of meaning, which is a different notion without language’s transparency. These meanings are the result of historical and reading memory, in this way, we have some recognized specialists controlling the interpretation, such as teachers do in class. (ORLANDI, 2001).

In addition to the view of DA, language is made by what is said and unsaid, “For my words to have meaning, they need to make meaning.” (IDEM, p.34). Although the same can be said for the unsaid and unconscious subject, this results from an ideological mechanism in which the interlocutor believes in the unity and completeness of his/her discourse. His/her text/speech is complete and has only ONE meaning.

However, discourse is built on the multiplicity of meaning indicated in the relation between this discourse and other discourses, and in discursive (interdiscursive) memory. Thus, all discourse is made by both what is unsaid and said.

With that, we think the opened possibilities for student interpretations are in the multiplicity of discourses that the teacher uses in class. For that, the importance of reading in science class.

[...] The reading allows the information diversity about different themes enabling the exercise of critical view […] even thought, there are others way to obtain of information, the written text is still the way that allows the amount of opinion and the deeply in variety themes. (ALMEIDA & MOZENA, 2000, p. 426)

Although the QM interpretation is predominant, the EPR Paradox made evident that it broke with the classical mode of doing science, even in terms of epistemology it is not accepted among physicists. (PATY, 2001). Therefore, nowadays a lot of knowledge production in physics is making use of the mathematical language in physics teaching even though there is the desire for prominence of the so-called “usual language” (ALMEIDA, 2004).

To understand the school as a place of citizen formation, ST should use the idea of physics as a culture (ZANETIC, 1989). The dialogue between teachers and students is better established though the use of the “usual language”, this being what a person uses to express him/herself. Especially because beginner students usually have a problem understanding and using the mathematical formalism intrinsic in physics. (ALMEIDA & MOZENA, 2000)

Reading in light of DA, the discourse writer writes a text focusing on the virtual reader, on the other hand, the reader interacts with the imaginary reader, then he/she creates a virtual writer. Thus, a triple dialogue is established between the real writer and imaginary reader; virtual reader with real reader; and the real reader and virtual writer. (ORLANDI, 2001). Reading of different types of texts in class is important as discursive heterogeneity enables these to apply physics as a culture (ZANETIC,1989), and it is approached in class, going beyond mathematical formalism.

For this reason, reading of a different discursive type can contribute to the students making sense of scientific concepts; they express their view on the topics brought up in class; they bring topics from their daily lives to the discussion; they are motivated by reading in general; they come into contact with aspects of scientific nature and it allows them to add new reading stories. (GAMA &ALMEIDA, 2006). Reading should be incremented in class not only as a motivator or auxiliary tool as some science teaching students defend, but it should instead amount to be the totality of class content. (ALMEIDA & SORPESO, 2013).

Reading is the main topic of the class, the primordial material such that, more than content, it should include the text form. (PIASSI, 2013) To understand a discourse it is necessary to comprehend the writer and, if translating from an original, analysis of the context of the reading of the “original discourse” should be considered. It is fundamental to understand some of the life of the writer, the translator’s conception of the world, and how the latter is shown in their discourse. Also, construction of the aforementioned form and content is given by how we say what is said and by the unsaid.

From book to writer and to translator.

The book is made up of many scientific, police short stories, which are narrated throughout the book. Moreover, characters such as Sherlock Holmes, detective created by Sir Arthur Conan Doyle (1887-1927), together with Dr. Watson, doctor and the stories’ narrator, besides those, it involves a couple of physicists, Summerlee, theoretical, and Challenger, experimental; a chemist, museum director; and a general scientist, Mycroft, Holmes’ brother, who is a certified scientist .

In other works, we have discussed this book under the perspective of Science Fiction (SF). In those, unlike in Pinto (2009), who characterized some books under a view of canonic and non-canonic literature in the science-teaching field, he showed the discourse in this narrative is one of Popularization of Science (PS).

However, in this article, following the idea on teaching that we argue for, we decided not to categorize this book as either SF or PS, with the understanding that the line between SF and PS becomes thin when the latter is a fictional narrative. On the other hand, we researched the writer. As he acknowledged in his blog: he is a popularizer of science. Colin Bruce is an English physicist, who has a second degree in computer science. In his career, he worked in a multinational corporation for ten years, when after finishing his first degree he started to work until he developed his own software and decided to return to science.

He had left physics because some graduate professors in an advanced physics course, who put him off to embarking on a career in physics. Despite that, some years after finishing his degree, he started to publish articles and books, in which he developed physics within the view of PS, as he defined in his blog, with his last post in May 2015.

In his new view of science, he published an article to explain general relativity by Albert Einstein to laypeople. He then wrote a book with science fictional narratives. Furthermore, he participated in the open lectures in Oxford University in England, where he is a professor and researches nuclear fission.

In his blog, he shows an aversion to a kind of scientist, who has scarified and sold out the science. Therefore, he defends disinterested science, which is a view opposing the philosophy of science. According to Bachelard (1971), all of science results from a historical-social context, even though it constructs its own context, thus, science is not built on prominent social interest, it is done within social value.

We noted his position as a scientist and the science in his book “The Einstein’s Paradox and Other Science Mysteries Solved by Sherlock Holmes”, with Sherlock Holmes’ comment, written in the seventh chapter, “The Case of the Faster Businessman”, after explaining that elicitation is open in business, since scientifically improved instruments. “Sherlock Holmes shook his head – So much cleverness to richness can waste money as kind of millionaire card games quicker! (…)”* (BRUCE, 2002, p. 138-139, our bold).

Also in this chapter, the writer exposes the discussion and, how the scientist underestimates the other’s view. In other words, Bruce (2002) develops the characters of the theoretical physicist, Summerlee, and experimental physicist, Challenger, as arrogant scientists who place themselves above, especially in comparison to Dr. Watson, who is a layperson in physics.

(...) -‘Who is not competent in mathematics, must not enter here.(…)

- This was supposedly the inscription that there was the Platão’s school grade of logic, two thousand years ago, said Holmes. In this period the mathematics was a rudimentary discipline.

A person like you [Watson], who can make division and knowing until the Pitágoras’s mystical formula, was not only qualified as led the doormen amazed.

-Although that, I feel as a heretic coming in a cathedral: the angular rock could fall and crush myself as imposter! I joke.

(…) [Summerlee] He pointed to black board, where I saw Mycroft’s formula (Lorentz’s transformation).

-A bigger velocity than light speed implies a bigger beta than one, he said. This creates a factor for a space contraction and time that would be square root of negative number (…)

- Any real square root, Summerlee said. (…) Any real number, positive or negative produce a negative resulting as multiply by itself. We can define the imaginary quantity, whose square are negative, but it is a fiction mathematics, (…)

- A true answer of mathematician! He exclaimed (…) It can really imply in quicker moviment that the light, which is impossible, though it is far from useful description of why it is impossible, or what would happen if You try. A lot of mathematics proof is like that. It can be rigorously validating; however, it does not support any useful portrait of the described situation.* (BRUCE, 2002, p. 145-7, our bold)

We can observe the ironic note that the writer gives Summerlee and Challenger characters, as in their relation to science; but he atones for this when developing the museum director and Holmes’ brother. For example, in the fourth chapter, “The Case of the Sabotaged Scientist”, the museum director acknowledges the help of Holmes and Watson for the development of his ionizing radiation theory. Or, the Mycroft character, Sherlock Holmes’ brother, a certified scientist who always tries to explain Summerlee and Challenger’s view, especially to Dr. Watson, who, even though he is a doctor, he is a layperson in physics, which the doctor equates to theology, in other words, abstract complexity of little use. In answer to this view, Holmes says:

- For example, at the moment, we are suffering in anarchist infestation. Not the real anarchist, of course, but before a pandemic of matter.

[Telegram] “Last of anonymous for Times point It threat explode a bomb with same power at cotton gunpowder’s hundred thousands of tons in downtown of London on Tuesday point Please advise point Arndale” (…)* (BRUCE, 2002, p.154-5)

The book is divided into twelve chapters, each one with a story which involves a police case and a scientific theory. Only in the last chapter, is there Colin Bruce’s (2002) theoretical physics intervention, as he is a physicist. The chapter sequence is organized based on how theories have developed throughout science history.

The first chapter is on the physics of the pendulum; after, it goes onto thermodynamics; following, the atomic issues; in the fourth, the ionizing radiation question; subsequently, the dual aspect of light; next, the theory of relativity; in the seventh, the relationship between energy and inertial mass; following that, the fission and fusion question; after, photon-emission; next, quantic reality; subsequently, the Paradox of quantum physics with the question of CP realism; lastly, the theory on how the universe ends.

The translator Maria Luiza X. de A. Borges has written some books on translation and language in Brazil, some of which were won awards in 2010. She is a translator of classic books, for example, Zahar editor’s “The Sign of the Four” (2015) pocket edition. She gave an interview to Carta Capital in 2013, in which she talked about her view of translation, for her the translator must be as true as possible and he/she must not interact directly with the reader. Also, she mentioned how the teacher should evaluate the appropriateness of the translated book, for her, it is important to introduce the book to the student as a translation and the teacher should choose the translated book which better addresses his/her classroom goal.

For our analyses, we did not choose the translated book, because the only available one is by this translator/writer. According to her, the good translator should not appear in his/her text or interact with the reader. We observe the translator produce her discourse in her translation, because she does not use endnotes or comments to interact directly with the reader. Furthermore, even when she keeps original terms or expressions such as “establishment”, she does not justify or explain the reason for keeping them.

However, translation, while a discourse, is done through the relationship between translator-writer, translator-reader. Even if exact, with he/she trying to be true to the original text, preserving the poetic and the literal, the writer and translator are different subjects, thus the discourse is established in different contexts to different readers, especially if they create different virtual readers. Moreover, according to DA, we note the translator, Borges, is influenced by some ideological mechanism, which makes the subject/writer accept the unity of her discourse, the translator thinking it is possible to exactly reproduce the original discourse. However, the discourse in its multiplicity of meanings results in the discursive literality being lost.

Analysis

In the paper published in 1935 by EPR in the journal Physical Review, titled “Can Quantum Mechanic Description of Physical Reality Be Considered Complete?”, they posed a question involving the development of the interpretation of QM in view of CP . As the writers highlighted in the paper abstract, a complete theory is developed by a correspondence between the reality element and physical measurement, which can be accurately and precisely described in an unperturbed system. However, in QM two physical measurements, when there is “entanglement”, can be gauged from the same operator (physical measurements). And yet, some observable value commutates cannot be known in their plenitude in the same system, thus, hinting at some probabilistic states in which the particle can be. Therefore, QM does not answer in the affirmative so that both questions are complete and correct, and only affirmatives of those can be said to be a complete physical theory.

According to them, analyzing the focus of authenticities of the QM theory, they began by describing some of CP’s philosophic principles, in which they defined that there would be one reality element and only one quantitative physical value. In other words, a reality element would be related to a physical theoretical/experimental value.

In Bruce’s (2002) book, one of the scientists is an experimental scientist, who is together with Sherlock Holmes and Dr. Watson involved in mystery adventures, emphasizing the experimental physics aspect. However, the QM interpretation is developed first as theoretical mathematics and, only currently, due to the development of quantum optical tools, many concepts such as quantic “entanglement”, are being reviewed, some of which support the QM theory and others made deeper investigation of this theory possible. (ZOHAR, 2016; AOLITA et al, 2015; LADD et al, 2010) Bruce (2002) shows the technological difficulties surrounding QM’s experimental development in the following part:

(...) – Listen our own words rumbled. You [Summerlee] can have really certificated the principle, but in practical, it is so far of the any chemistry to know it. It is perfectly evident that someone is further in investigation than us in our performance in this new physics and seemingly also in your comprehension. Someone, who does not wish to cooperate with the scientific “establishment”, whose sympathies maybe are addressed crimes activities and until anarchist.

(…)

-Emit sign through during the time, it is not allowed, Watson. The universe is not too strange as. But, it seems without doubt too much weird. In right way, a victory of Pirro for Summerlee, I think: his mathematic prevail, but it produced one result in right measure to baffle the world.* (BRUCE, 2002, p. 224-5, our bold)

Although, before the writer had highlighted Holmes’ mentioning of two meanings of the word anarchist, drawing the distinction between the criminal and the real anarchist, in the last citation, the notion is different, with anarchism being associated only with criminality. We place stress on the emphasis that the writer gives to the question of scientific status quo.

In the EPR (1935) paper, they affirmed the need to verify the QM interpretation on quantum physics from the reality criteria of CP, and demonstrated the first with mathematics (wave probability function of light and particle) developed by Erwin Schrödinger. Despite this, Schrödinger’s mathematics is fundamental to QM theory, without which it is not possible to analyse the spin, together with QM and general relativity, for that matricial mathematics is necessary.

In the second part of paper, the writers describe the concept of “quantum entanglement” and even though they did not use those words, they discussed the idea and defined the “entangled” systems notion. They recommended, therefore, nonlocality, in other words, the simultaneous action in which a system can affect another, independent of how far apart they are.

According to this mathematical view of wave function and entanglement it is possible to associate more than one quantum object with an auto value even though it is not possible to precisely know the probabilistic view of the quantum object, and this allows us conclude that QM is not a complete description of physical reality.

We observe in two of Bruce’s (2002) chapters, “The Case of the Faster Businessman” and “The Case of the Deserted Beach”, in which he presents a similar idea and conclusion to EPR. In both chapters, he concludes the speed of light in a vacuum, a velocity reference – the line between the classical and relativistic worlds – would make the occurrence of quantum entanglement impossible, in theory it would be the same as saying there are two simultaneous states for the same quantum system:

(...) – Very good, doctor, he said seriously. Now, you consider that my imaginary train (…) with one second-light of measure (…) with any super-telegraph (…) this telegraph work instantly.

Now, you consider the follow sequence. The man, who is close of the train rail, makes signal to train driver when he passes. The train driver transmits the signal for the police.

(…) You remember that two events, they happen simultaneous of train driver and police view, for any observer together the event in direction of police happen more than train driver (…) Therefore, the view of who are with you in train rail, the police receive the message more than it will be send!* (BRUCE, 2002, p.150-1)

We highlighted some concepts of physics mentioned in the citation above, for example simultaneous occurrences between two systems – “quantum entanglement” - one of the reasons EPR invalidated QM, the same is in the book. Mycroft thinks it is impossible that a velocity faster than the speed of light exists in a vacuum. Also, we emphasize some of Mycroft’s views in relation to science, such as unchanging and certain absolutes.

In the tenth chapter, the discussion’s focus shifts to another topic, on the duality of particle behavior. It begins with Challenger, a scientist, commenting with Dr. Watson on the experiments that have been done with the advancement of technology to prove the electron wave theory. He and his adversary; Summerlee, also a scientist; have attained more accurate results. While one performed experiments involving wave theory, the other conducted experiments on corpuscular proprieties. Even more, they decided to execute the crucial experiment to remove all doubt surrounding particle behavior. This experiment was the double-slit experiment, which surprised both, evidencing the particle’s behavior as dual behavior.

In this chapter, we note that Challenger, a scientist, mentioned experiments that have been conducted in the real world during the process of scientific knowledge building, these being the same experiments described by Challenger to prove the wave and corpuscular theory of particles. A similar double-slit experiment was performed and with the same goal in the history of science. As such, later, the writer discussed beyond the real experiment, he described the ideal experiments, which were proposed in conferences and papers that resulted in polemic and debates, such as what happens in the book with the argument between Summerlee and Challenger.

- The poor man [Summerlee] declared he does not believe in wave, only in probabilities wave. Challenger tapped suggesting in his head. He supporst the atom’s position, electron’s position or anything else only can be described by probabilities distribution until that are measure. Thus, some way, the mere act of measure make the particle gain short occurrence in define place in probabilities field.

(...)

Challenger shook his head. – It is more than that, sir [Summerlee]. That are interested it is the surf particle, which can never really transport information faster than the light. It is guided by waves and not the opposite and the mere act of surf particle analysis cracks its pedestal above light speed. Because of that, even in one inferred sense, it moves faster than light, any influence or real message can be transmitted through their, then, any paradox can happen.

This sounded somewhat doubted, but Summerlee only agreed with that (…) (BRUCE, 2002, p. 204-5 our bold).

In this part, the scientists conclude the impossibility of “quantum entanglement”, meaning the particle cannot transport information faster than the speed of light. Further, they discuss the concept of wave probability and the “observer effect”, because of the last, when we measure a system, it is collapsing the “original” system, as described. Dr. Watson’s ignorance in topics of physics allows him to question without the prejudice of CP.

On the other hand, if both these chapters are supported by EPR’s idea, the chapter “The Strange Case of Mrs. Hudson’s Cat” is focused on explaining the QM conceptions on “quantum entanglement”. The writer begins the chapter to warn about the danger of QM development on our perception of reality, which was especially discussed at length between Einstein and Bohr, in the 1930’s.

-Mycroft is unsatisfied with that for two points, Watson. First, there is the particle’s question, it is moved faster than the light in its surf. It is not completely clear, that it can give us paradoxes consequences. The second, there is a question how the mere realization of an observation can be reduced immediately all the possibilities in one result.

(…)

Holmes smiled – Your lay is peaceful, Watson, said. It was exactly what I tried to argue with him. But he insists that “observer’s effect” is stronger as the observation presence in many different situations, the details of the measure’s way being choose could be completely indifferent. The presence of any effect would be able in principle to amplificated the quantic system’s state change, therefore, the surrounding environment in way that can be measured subsequently, it alters its system behavior. That is the availability and the acquisition of mere information about the system affected its different of the previously by others known physic laws and it is not explicable by them. (BRUCE, 2002, p. 209-10)

Mycroft’s view is similar to that of Albert Einstein (1982) in that, he explained his dislike for the development of QM , which caused him to begin investigating a new field of physics, believing this way, he would be able to describe reality precisely and realistically. In this chapter, Bruce (2002) also mentioned Bohr (1958), who explained the statistics of QM , which is not limited to using the law of probabilities, because it involves complex and abstract concepts, for this reason a statistic with the probability of a quarter can have an infinitesimal chance of occurrence.

We observe in the abstract of Niels Bohr’s (1935) paper, a direct answer to the EPR paper, in which he showed QM as a dual interpretation of light and particle, enabling the description of physical reality in its totality, thus, QM is a complete theory, the conclusion he reached being contrary to that of EPR (1935).

However, unlike the EPR paper, he did not use a lot of mathematical language, instead he argued for using common language as he wanted to introduce his theory of complementarity. He used the concepts of physics defended by Copenhagen’s school as cited by EPR (1935). The mathematics in the article is essentially shown in footnotes, with Werner Heisenberg’s mathematic formulation differing from the probability wave function as EPR (1935) had used.

We note Bohr (1935) agreed with EPR (1935) that QM is not in accordance with the reality of CP, but he defended that a shift should be made in CP’s episteme and not QM, like an incomplete theory, because the former cannot support other theories, such as not only QM, but for example General Relativity.

He addressed the theory of General Relativity, which had brought a shift to physical reality, no longer supporting a more classical view. This theory introduced the “observer effect” and also joined time and space into a single measure. He highlighted QM really had shifted the comprehension of physical reality, akin to how General Relativity had impacted CP.

Similarly, in the book, this is apparent with Summerlee and Challenger, when they assumed the phenomenon was not explained by CP, they said, “it is necessary to do radical action”, that is, a shift in paradigms. In addition, they associated the topic of QM with the question of relativity and the observer, as Bohr (1935) did.

- Now – he looked me furious – it would seem evidently it is not possible there is any communication between two photons. Each one takes its own decision, in this way, in terms of rebounding or not.

- It is obviously for me, I said. In fact, as the photons reach the filters at the same time, and any kind of signal can pass faster than light speed, it is clearly impossible that a collision can affect each other at all events.

Challenger open a big successfully smile. – That is, he said. But see, until one or other are measure, the photons constitute the unique quantic system, whose estate is indeterminate: it is a mere superposition of probabilities. At least, it is statistic theory of Summerlee has said to us.

(…)

Challenger shook strongly his head. – (…) any formula, for more complex that be, which can explain the result, only if the photons are in some way, which is impossible to be a communication between them.

(…)

He emitted an hollow groaning – It does not escape only the comprehension; to escape the common sense, even it be dispose to formulate the most absurd hypotheses (…) Summerlee and I are discussing if, after all, some signal are faster than the light can pass between two photons.

Even, in this case, there would be a problem to know which photon affect the other, because of the relativity that said to us the apparently sequence of events is purely a question of reference system. For observer, who travel to east from laboratory, for example, the left photon achieves the first target, and he pointed the left tip of instrument. But for observer, who follow to west, the right get the target first. Therefore, for observer, the left photon should decide its action first place, controlling after its behavior of the other. For other observer, it is the right photon, which decide and the left should follow it. It is the view less logic*. (BRUCE, 2002, p. 221-3 our bold).

Final words

We can highlight the importance of this type of work in the classroom, because of the scientific outcome that has been explored for the paradox proposed by EPR. Thereby, if one or another position is corroborated experimentally, it can bring big changes within the logical way to do science and/or perception of the world and worldview, with science, in particular, physics as a culture, a way to be in the world.

Notes

* As we did not have access the English version.

**The original Bohr’s book version.

*** English review by Fernanda N. Lotz Alves.

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Perceptions of Early Intervention Professionals and Parents About the Use of Ages & Stages Questionnaires (ASQ-PT): Defining the Research Methodology

Rita Laranjeira

Ana Maria Serrano

Education Institute, University of Minho

Abstract

Developmental screening tools should enable to identify children in need of a more specific assessment, those who need no support and those who need to be monitored periodically.

The Ages and Stages Questionnaires 3rd Edition (ASQ-3) is a screening tool that promotes family involvement, with health and education professionals, to identify developmental problems in children. In Portugal, this instrument was calibrated and adapted for the child population and is called ASQ-PT.

We intend to carry out a qualitative study to understand perceptions of health professionals, education professionals and parents about the use of the ASQ-PT in Early Intervention. Our goal is to aware professionals to the use of this tool by collaborating with families in the screening process. Also to understand the impact of parents questionnaires filling (ASQ-PT), on the knowledge about their child, and on the collaboration with professionals.

Participants in the study will be professionals from three Local Early Intervention Teams (LEI), health and education professionals and parents of children screened with ASQ-PT.

We will introduce ASQ-PT to LEI, health and education professionals to understand the use of ASQ-PT intending the instrument’s future adoption for screening, focusing on the advantages and disadvantages of its use and its power to empower parents, actively involving them and giving them new knowledge to promote their children development.

Keywords: early intervention, development screening, eligibility, family’s empowerment

Introduction

Early intervention (EI) should be initiated as early as possible, thereby increasing the possibility of being maximized the potential of development of child with special needs or at risk and their family.

In EI, in the last decades, a change of paradigm has been observed, from a child-centered model to a family-centered model, where the child's life contexts and family decisions are valued. Evaluation maintains a central role and may have different objectives: definition of child's eligibility, intervention’s planning and evaluation, as well as monitoring of child's progress (Bagnato, 2007). In the evaluation process it is still observed the predominant role of the professional to the detriment of a more active and collaborative participation of the family. However, it is assumed that the evaluation in EI is flexible, collaborative between parents and professionals in the decision-making process, so the instruments used should be chosen according to the evaluation objective.

When defining the eligibility of children referred to EI, screening instruments should allow to identify children who need a more specific assessment, those who do not need support and those who need to be monitored periodically. Family’s involvement in screening is very important as its elements are the ones who know the child better. Also the family has a preponderant role in the child development so they can learn about development through the screening process.

Ages and Stages Questionnaires 3rd Edition (ASQ-3) is a screening tool used for more than 20 years and intends to guarantee the good development of children. It promotes family participation, in conjunction with health and education professionals to identify developmental problems in children and, at the same time, creating opportunities for promoting new skills. This instrument is easy to administrate and easy to understand and is expected to be completed by parents and caregivers with the collaboration of professionals to interpret the results obtained.

ASQ-3 is composed of 21 questionnaires distributed over well-defined age ranges: 2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54 and 60 months. Each questionnaire has 30 questions covering 5 development domains: communication, gross motor, fine motor, problem solving and personal-social areas. Additional information about vision, hearing and other parent concerns and concerns about the child is also requested. It takes about 15 minutes to complete.

In Portugal, this instrument has already been standardized and adapted for children and is called ASQ-PT (Lopes, Graça, Teixeira, Serrano & Squires, 2015). According to Lopes (2013), Graça (2013) and Teixeira (2013), the results of the ASQ-PT studies (2 to 60 months) showed that this tool meets the requirements of a validated screening instrument for the Portuguese population and allows early identification of children with developmental problems.

The purpose of our investigation is to conduct a qualitative exploratory study to understand professionals of EI, health professionals, education professionals and parents perceptions about the use of ASQ-PT for screening and parental collaboration in this process. The aim is to sensitize EI, health and education professionals to the use of this instrument and to collaborate with families in the developmental screening, as well as to understand the parents' filling of ASQ-PT impact on the knowledge of their child and the collaboration between professionals and parents.

In order to develop this study, we will introduce the development screening tool to Local Early Intervention (LEI) teams in order to know their use perception intending the instrument’s future adoption for screening. Our study will focus on advantages and disadvantages of its use and its power to empower parents by actively involving them in this process and giving them new knowledge to promote their children development. The instrument will also be presented to family physicians in health centers, to pediatricians in hospitals and to child educators in day cares and kindergartens in the LEI’s geographical area, as a way to raise awareness of the use of ASQ-PT, since these professionals are responsible for the process of early detection of child developmental problems.

State of Art

Early intervention is defined by Shonkoff and Meisels (2000) as the set of multidisciplinary services provided to children from 0 to 5 years old, with the following objectives: promote child health and well-being, increase emerging skills, minimize developmental delays, remedy existing or emerging disabilities, prevent functional deterioration, and promote parental adjustment and adequate family functioning.

EI is more effective when its professionals work together with each family in an individualized way, delineating and organizing together the resources, social supports, information and services necessary for the family to be able to adjust its functioning. Goals and strategies should also be well-defined for the family to understand how the child's development works and to have a positive impact on their social and cognitive skills. According to Guralnick (2001), the studies that have been carried out over the years in United States of America about EI continue to show favorable results regardless the child’s disability or type of risk. Although there are several conceptual frameworks, objectives and forms of intervention, the guidelines and theoretical models on which EI is based give consistency to the different practices, and their dissemination and implementation in other countries, among them Portugal.

EI is based on Bronfenbrenner's theoretical models of human development (1979; 2002) – Ecological Systems Theory of Development - and Sameroff and Chandler’s (1975) - Transactional Model of Development – assumptions as well as the models that are a reference to EI, Dunst and his contributors’ Family Centered-Practice Model (Dunst, Trivette & Deal, 1988; Dunst, 2000) and Guralnick’s Developmental Systems Model (2011).

The first two models assume the central idea that the child and the environment’s characteristics are not tight and they are changing at every moment. The family is a model of identification, of protection, where the child receives information and guidance, where establishes interactions, where acquires skills and has access to diversified and significant learning experiences. The transaction’s characteristics established between the child and the environment are related to changes in the child behavior or attitudes and are directly related to the behaviors and attitudes of others in the context in which they are inserted (Sameroff & Fiese, 2000). These transactions happen over time, from one event or experience to another that occurs later, making that influence permanent. All this process takes place in environments that the child and the family influence, causing constant changes.

Bronfenbrenner’s model (2002) allowed to understand the organizations of life contexts of the child and the family, taking as its starting point the existence of three categories: the child, the family and the community. Although different from each other, these levels are considered interactive as they influence each other. Children are thus involved in a constant and dynamic process that occurs in several contexts and includes four systems: microsystem, mesosystem, exosystem and macro-system, and their development is directly or indirectly influenced by the interactions that occur in the various systems.

Microsystem is the immediate context that directly affects the child in development, the activities and roles that she experiences, the places where she spends her time, the people with whom she interacts and the bonds created. The mesosystem includes the interrelation of environments in which the child develops and participates actively. In this system are included the relationships between professionals, family and community that will produce interactive effects on the child and the family. The exosystem comprises environments that do not directly involve the developing child but affect what happens in her immediate environment. It concerns health services, social groups, media, among others, that will intervene with the family as a way of response to their needs and those of the child. The macro-system comprises the cultural context, beliefs and values ​​that govern a particular culture within which the child develops (Bronfenbrenner, 2002, Serrano, 2007).

From a systemic and ecological perspective, Dunst and his colleagues developed a set of principles in families’ support work designated by Family-Centered Practices (Dunst, 2000). ​
This model is based on family priorities, emphasizing the positive outcomes and strengths of both the child and the family and works on the family's ability to control and strengthen family functioning. The whole family is considered as an intervention unit, with no specific focus on the child as advocated in a more clinical model. Therefore, it is considered that the welfare of the family affects all its elements and their interactions. The child is not at the center of the process, but rather all the elements of the family, and the intervention by the professionals intends to respond to the needs of the family, minimizing stress, contributing to a good relationship between their elements to promote a good family functioning.

In Family-Centered Practices two key concepts are highlighted: enabling and empowerment. Enabling translates family’s ability to meet needs and achieve control over their family functioning; and empowering is to strengthen family skills through information, collaboration and support to families in seeking strategies to address the problems they encounter in dealing with an infant with special needs, thereby strengthening family functioning (Dunst, Trivette & Deal, 1988). A family-centered intervention is guided by the family itself in order to respect the child’s development, based on the developmental aspects that the family defines and considers to be more important.

Guralnick (2011), with Developmental Systems Model, aims to realize that development mechanisms are involved in promoting child development in the context of EI for vulnerable children and families. It presents the factors that can be considered as risk or protection and that work in three interrelated levels: the social and cognitive competences of the child, the patterns of family interaction and the resources of family. The child uses the interconnection of her developmental resources and the organizational processes to increase her competences, being these domains interrelated. At the second level, important environmental factors are identified in the child's development, especially in the interaction between family members. This interaction arises through transactions between the child and mother/father, where there are relational processes that are developing between the two and allow to define each one role. The third level encompasses the parents’ personal characteristics, which gives them stability and makes them self-effective in their role as parents, and the resources that influence the decisions to be made and the direction that EI will take.

EI should start as soon as possible with children and their families to be more effective, and the child is more likely to overcome or reduce the difficulties that result from her risky situation (Shonkoff & Philips, 2000; Bairrão & Almeida, 2003; Brassard & Boehm, 2007). Gains are considered significant, favoring the child's overall development, optimizing her developmental potential, involving and empowering families to help their children acquire skills.

In order to prevent the emergence of developmental difficulties or to reduce the impact of the difficulties that children already have or may present due to biological or environmental conditions, early identification of children becomes essential. The identification of children with special needs or at risk of developmental delay is of great importance to instituting an adequate and timely intervention before the difficulties of the child interfere significantly in their life and that of their family.

The emphasis of early identification is placed on the opportunity for children to benefit from EI, so it poses a challenge to screening by health professionals (American Academy of Pediatrics, 2001), and also the need of a bigger involvement in screening of education professionals, all contributing to the same goal.

Each country should create an appropriate developmental screening system to detect, at an early stage, children with special needs or at risk of developmental problems. In order to achieve the creation and operation of a screening system, it is vital that a local and regional network is formed where there is collaboration between institutions and professionals. Professionals of health services, social services and education services should be aware of the factors that may lead to changes in children development, paying attention to the warning signs and taking into account the information and concerns of the parents. Early identification is an opportunity to demonstrate the benefits of screening and to present the benefits of EI.

Evaluation plays a central role and can have different objectives: screening, eligibility, intervention evaluation, monitoring of progress and evaluation of the program (Bagnato, 2007; Bricker, Allen, Clifford, Pretti-Frontczak, Slentz & Squires, 2008). Screening allows, through the use of briefly performed tests, to determine if children are developing in an expected manner for their age. If necessary and after screening, children should be referred to EI or other services deemed necessary, where they can access an assessment, and determine if they are eligible for these services. The intervention evaluation aims to determine the goals to work with the child and the family. Monitoring is about observing the child's progress after intervention and development of defined goals. The evaluation of the program refers to making global comparisons over time.

According to Dworkin (1989), developmental screening is the process of monitoring the child population to identify children who are at risk of developmental delay. It is a rapid evaluation procedure that allows the detection and identification of children who have developmental problems, those who are at risk, needing a formal evaluation, and those who have a development adequate to their age (American Academy of Pediatrics, 2001; Glascoe, 2005; Meisels, 1989). Its importance is related to malleability of development and to manifestations that occur over time and are only detected at specific ages (Glascoe, 2005).

Developmental screening should be used with children whose development is questionable or with children at risk (Bricker et al, 2008). Investigations have determined that biological and medical indicators are not predictors of subsequent developmental delays (Squires, Twombly, Bricker & Potter, 2009). Developmental screening should let know the progress to be made in children development, determining further steps at a time when measures that will have a significant impact on children lives can be taken. In a long term, screening is a way to ensure children's success in school and life and should be seen as a priority.

A developmental screening involves the application of tests at specific ages, which may cover all or just one developmental domain, depending on the instrument chosen. The tests used in this process should be easy to apply, standard referenced, be economical, appropriate, objective, address all developmental areas, have reliability and validity for the target population (Dworkin, 1989; Meisels, 1989).

The screening process should be efficient and the instrument used should be easy to administer and easy to interpret. Screening planning should enable practitioners to determine their purpose to ensure that the chosen instrument is appropriately selected, also outlining their frequency, the ages and characteristics of the children, the time required and who should be involved and how (American Academy of Pediatrics, 2009). It is considered central that all children have access to developmental screening and the role of family physicians, pediatricians and EI teams is essential.

Parental involvement is essential at all stages of evaluation. In addition to their knowledge and concerns about the child, parents assist in planning or screening as process assessors and intervention facilitators (Brassard & Boehm, 2007). Professionals should value the concerns of parents, who are the first to be aware of some developmental change that can be difficult to detect in child health consultations.

During the evaluation process, the necessary information can be gathered through various processes and organized to present a comprehensive view of the child's performance in real, authentic and meaningful situations over time (Bagnato, 2007; Brassard & Boehm, 2007). The evaluation may include several professionals and the child's family as a key partner in the process. The professionals present in child’s evaluation should be attentive to the questions that parents can put on the process that they are experiencing with their child, the services available and the steps to obtain those services.

Parents are the greatest source of information about the child, they are also the child's first educators and her best knowers. When parents participate on child evaluation, the professionals obtain more information about the child, promoting an opportunity to establish a relationship and a partnership between parents and professionals. In the evaluation process, parents decide where this will occur and what role they will play. By involving the people with whom the child has familiarity, the results obtained will be more accurate and reliable.

Parents or other child care providers have specialized knowledge about the child, so active participation in the screening process is critical. They provide valid and essential information that would otherwise not be known. Studies have corroborated that the information provided by parents is a predictor of developmental delays and can effectively identify these delays (Bricker, Squires & Potter, 1997; Glascoe, 2000; American Academy of Pediatrics 2001; Bricker et al., 2008).

Parents during screening gain access to developmental knowledge, being empowered and thus becoming more competent and aware that they are intervening positively in their child’s development. Thus, parents go from mere observers to active elements, facilitators and promoters of the intervention, initiating this process at screening time.

It is assumed that both the identification and evaluation in EI are flexible and collaborative, involving parents and professionals in the decision-making process, so the evaluation tool used should be chosen according to the evaluation objective. We consider ASQ-3 to be a screening tool that meets the requirements to be used in defining the child eligibility for EI and at monitoring moments as it was built to be used by parents and caregivers.

This instrument comes up from the work done since the late 1970s by Diane Bricker and Jane Squires, as well as their collaborators. In the United States there was the need to involve children parents and families in identifying, assessing and intervening with children with Special Needs or at risk of developmental delays; lack of existence of tests and procedures to screen and monitor the development of children at risk of developmental delay due to established, biological or environmental factors or a combination of these factors; to find an economical but effective screening tool covering a growing number of children at risk of developmental delay and their families (Squires, Twombly, Bricker & Potter, 2009).

The instrument authors reserve two important assumptions for their use: most parents accurately report whether or not the child is able to perform certain behavior (Bricker et al., 1997); ASQ-3 should not be used with children with special needs as they, because of their specificity, can move immediately to the evaluation process.

The health, education and social service professionals who have used this instrument consider it an effective and low-cost measure to identify children with developmental problems (Squires et al, 2009).

ASQ-3 is a meaningful tool to share with parents and to make the most of their knowledge about their child, managing to involve children in a fun way. It emphasizes the child strengths and areas of lesser achievement, emphasizes the results found in the monitoring zone, making it easier to monitor children at risk. It is an instrument that can be completed at home, at pediatrician’s or physician’s waiting room, on a home visit or by telephone.

As mentioned before, ASQ-3 is composed of 21 questionnaires distributed over well-defined age ranges and screens children between 1 to 66 months. Each questionnaire has 30 questions, screens 5 development areas (communication, gross motor, fine motor, problem solving and personal-social) and request additional information about vision, hearing, behavior and other parent concerns about the child. Its completion takes about 15 minutes, being quickly quoted by professionals.

In Portugal, this instrument was standardized and adapted for the child population and it´s called ASQ-PT (Lopes, Graça, Teixeira, Serrano & Squires, 2015). From the investigations carried out, Lopes’ study (2013) focused on the questionnaires of the ages between 2 and 12 months and presents the data of a sample of 441 children. Teixeira (2013) follow up the study with the questionnaires of the ages 14 and 27 months and presents data of a sample of 541 children and Graça (2013) conducted a study with the questionnaires between the ages of 30 and 66 months and presents the data of a sample of 926 children. The psychometric measures of ASQ’s translated version of fidelity and validity were calculated and the first one included studies of internal consistency by Cronbach's alpha values ​​and Pearson's or Spearman's Rho's, test-retest and interobserver agreement. The second covers the factorial analysis and the comparative studies in a risk sample and a sample in a therapeutic follow-up.

Methodology

In the National Early Intervention System (NEIS), the LEI process starts with a child referral. However, it is found that at national level the process is not uniform, varying in terms of evaluation planning, parents involvement, time and use of evaluation/screening tools. In addition, the use of instruments specifically designed to identify children with developmental problems is rare in Portugal. This identification is based mostly in the observation made by pediatricians, health physicians, nurses, child educators and other professionals, leading to a potential failure to identify children with developmental problems. It is important that this initial process is more homogenous so that children have the same opportunity to be supported by EI, increasing the probability of maximizing their potential. The eligibility process of a child to EI should also be faster so that professionals can respond more effectively to identified needs. Also, since parents are the people who know their children best and who play a key role in their development, they must play an active role throughout the process and at the same time learn about development.

Thus, the objectives of the research that we intend to carry out are:

- know the perceptions of LEI, Health and Education professionals about the use of ASQ-PT for screening;

- know the perceptions of LEI, Health and Education professionals about the parental collaboration in the screening process;

- know parents' perceptions about the use of ASQ-PT for development screening;

- know parents' perceptions of their collaboration in the screening process;

- sensitize EI, health and education professionals to the use of ASQ-PT.

With our investigation we intend to carry out a descriptive and multiple case study. It is a case study because it intends to investigate a phenomenon in its real context, focusing on the particular, specific and singular (Stake, 2003).

The case study to be performed is descriptive because it describes the intervention and the actual context where it occurred (Yin, 2009), in a complete and detailed manner. It is multiple because it is intended to study more than one case, investigating various aspects of the same phenomenon, under common conditions and characteristics and implying multiple sources of data, which will allow a deeper knowledge about the phenomenon under study.

Participants

The participants of our study will be professionals from 3 LEI (one in the north zone, one in the central zone and one in the Lisbon and Vale of Tejo zone), family physicians, pediatricians, child educators and families. In this way, we intend to cover professionals whose primary function is to carry out primary prevention in the early identification of children with developmental delays or who are at risk of developing delays, as well as families whose children have been screened with ASQ-PT.

Procedures

In order to carry out the study, we are reviewing this process through a critical analysis of the bibliography in the EI area pertinent to the subject of screening and the active participation of parents in this process, namely screening effectiveness, screening advantages, screening instruments and ASQ-PT description, family-centered practices and parental empowerment. The data collection will be done through the use of interview, so we elaborated script interviews for the EI, health and education professionals and for parents and we will outline the presentation of ASQ-PT instrument to professionals.

The study will be further developed in a series of steps:

Stage 1 - Authorization request

In order to be able to use the ASQ-PT development screening instrument, we obtained authorization from Brookes Publishing and the authors of the Portuguese version. We are processing the authorizations of the Ethics Committee of the University of Minho, of the Regional Subcommittees of the NEIS to carry out the research with LEI.

The definition of the LEI that will participate in the research will be carried out through the presentation of the study and will have as an inclusion criterion the availability of all professionals to collaborate in the use of the screening instrument.

We will also request authorization from Health Center Groupings, Hospitals Directions, School Institutions and Private Social Solidarity Institutions Directions to present the ASQ-PT in health centers, hospitals, day cares and kindergartens from the geographical areas of LEI that will participate in our study.

Authorization will be requested for all professionals and families that will participate in the research, following the ethical procedures of informed consent and guarantee of anonymity of the participants.

Stage 2 - Presentation of the instrument to LEI, health and education professionals

We will meet with each LEI to present our study, the ASQ-PT screening tool and do an initial group interview.

We will also present our study and the ASQ-PT screening tool to health professionals in health centers and hospitals and education professionals in day cares and kindergartens in the LEI geographical area.

Stage 3 - Data collection

Through telephone and/or email contacts with the LEI, health and education professionals, we will try to understand how ASQ-PT is being used and the families acceptance to participate in the study.

To collect data, we will conduct interviews with LEI professionals, health and education professionals and families whose children have been screened with ASQ-PT.

With LEI professionals, we will carry out interviews in two different moments: at an initial moment and after the use of the screening instrument by the professionals and the parents.

With the initial interview we intend to know the LEI’s procedure when a referral is received: who contacts the family, if the family has the possibility of choosing the place and time, who reunites with the family, who evaluates the child, what evaluation instruments are used, how much time this process takes and what is the degree of involvement of parents in the process, using as reference the ASQ-PT. In this way we will also be able to perceive the functioning of the different LEI and the similarities or differences between them during this initial phase.

For the interview of LEI professionals, health professionals and education professionals, after the use of ASQ-PT, we have the following objectives:

- know the advantages and disadvantages of using ASQ-PT;

- understand the collaboration of families during the use of ASQ-PT;

- understand how ASQ-PT helps professionals to value parental involvement.

We will try to understand how screening has been prepared, including the role of professionals and parents; the parents involvement on filling the questionnaire; what was the parents’ interest and understanding about ASQ-PT.

The interview with the families will be carried out to the elements that are present during the ASQ-PT screening, in order to have a perspective of their perception of how the screening process took place, what were their feelings about the process and what was their involvement during their child screening and their knowledge and empowerment during the use of ASQ-PT. This interview will have as objectives:

- know the families perception about the use of the instrument;

- perceive the families’ type of collaboration during the child’s screening with ASQ-PT;

- understand families’ interest and understanding about their child's development.

Stage 4 - Data analysis

After the interviews are carried out, these will be transcribed to allow performing a future content analysis of the data obtained and subsequently to establish themes and categories.

We intend to understand if the perception of LEI professionals and the Portuguese parents is similar with the research carried out in other countries where the ASQ instrument is also validated, so that the future use of this instrument in Portugal can be an added value in the identification and screening of children with developmental problems. The use of this tool will facilitate the NEIS’s screening development as well as the children who are supervised in LEI monitoring, while ensuring greater involvement of parents in this process as well as their empowerment. It will still allow health and education professionals do an early detection/identification of all children with developmental problems.

References

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Gender Issues in Perspective:an Educational Experience

Sofia Veiga

Abstract

Raising awareness of gender equality issues should start at an early age across every contexts of socialization including family, peer groups and school, among other instances. Through that, children and young people build, internalize and assimilate a social representation of what it is to be a man or a woman, according to the values, stereotypes and ideologies prevailing in the different realities.

Playing a vital role in citizenship-formation, schools encourage students to think and reflect on various contents related to this subject - namely the fact that gender is perceived in many realities as a legitimate and ideologically admissible basis for demarcation of rights, duties and powers, with an impact on the assumption and division of different roles -, (re) analyzing and (re) signifying their values, concepts and practices.

Based on this conception, the present work exposes and analyzes an educational experience which, using Sociodrama as a teaching-learning methodology, allowed students to deconstruct stereotypes and prejudices and collectively acquire knowledge related to this subject in an active and experiential way, with a view to adopt a reflexive, critical and interventive posture as citizens.

Keywords: Gender Equality; School; Sociodrama

Introduction

Gender issues are a current and global challenge. In many realities, including Portugal, gender is still viewed as a legitimate and ideologically admissible basis for the delimitation of rights, duties and powers. This understanding has motivated political, social and civic movements to look at this reality and develop measures, projects and interventions to combat gender-based discrimination. The most recent example is the announcement made by the portuguese Secretary of State for Citizenship and Equality, on February 14, 2017, who, aware of the prevailing culture between men and women, proposes preventive measures to combat violence and gender stereotypes.

Gender issues in perspective

Understanding gender issues requires a clarification of the phenomenon in analysis. Gender concerns to the culture construction of female and male identity. Despite all societies taking the basic distinction between male and female according to the physiological characteristics related to procreation and biological reproduction, it is through development and within social contexts specificities that the gender identity is built, often marked by stereotypes and prejudice associated to discriminatory practices. Stereotypes are representative of the culture and time in which they are inscribed and provide a legitimate basis for – open/covert and/or hostile/benevolent – practices of discrimination and exclusion (Ferreira, 2004). The way sterotypes are conveyed includes information that is received from the family, peer groups, school, among other contexts of socialization (Quaresma, 2010; Ryan & Jetthá, 2012).

The Commission for Citizenship and Gender Equality (2015), as well as a number of studies have pointed out the need to deconstruct gender stereotypes and consider practices that contribute to building a sense of life that reflects principles for an egalitarian and solidary citizenship, in accordance to the Universal Declaration of Human Rights.

"Citizenship education is a lifelong process. It starts at home and/or the children’s immediate context with questions that arise in everyday life about interpersonal relationships, identity, choices, justice, good and evil, and develops as their life horizons expand" (Cardona, Nogueira, Vieira, Uva, & Tavares, 2010, p. 59). Schools play an important role in encouraging children and young people, as citizens in development, to think of gender inequalities throughout history and in different cultures/societies and reflect on the fact that gender (still) legitimize, in everyday life of most realities, the differentiation of rights, duties and powers, with an impact on the adoption and division of different roles.

Since the earliest decades of history, the distinction between male and female have been based on relations of dominance/submission, superiority/inferiority, essentially translated into the overvaluation of the male against the feminine imperfection. Given their biological and psychological characteristics – and legitimized by religious, cultural, political and social values conveyed by agencies of socialization (Laresma, 2010, Ryan & Jetthá, 2012) –, men have assumed roles that require greater competence, autonomy and decision-making. For the same reasons, women have historically assumed roles related to serving and caring (Nunes, 2007).

Despite the social changes and gradual valorization of women observed in the last century – especially with women's access to education and the labor market, as well as with the progressive adoption of traditionally male/female roles by women/men – gender stereotypes continue to influence expectations for female and male roles and functions, as it will be explored below.

Beliefs and conceptions

According to Marques, Paez and Pinto (2013), there is still a belief that females are more emotional, sensitive, maternal, obedient, fragile and vulnerable, and males are more adventurous, relaxed, extroverted, dominant, strong and disorganized. These beliefs denote the roles and duties that are attributed to and assumed by men and women in our societies. Men tend to assume roles of high status and remuneration and are entrusted as head of the family, meanwhile housework and familycare represent the primary responsibility of women, in a reflection of the femininity stereotype (Oliveira & Amâncio, 2002).

Professional dimension

The gender-based division of the labor market is not a natural phenomenon but rather the result of historical, political and ideological conditions and different socio-economic systems. Despite the changes that took place in the last century – with the entry of women into the labor market and access to education – a stereotyped division of labor still prevails based on significant differences in career opportunities, income and finance control. Men usually earn more for the same functions and the top jobs are generally given to them, even though there may be women more qualified (Cerdeira, 2009). Within the professional context, women continue to have more difficulty entering into the labor market, since men are preferred, especially because they do not become pregnant and are able to devote more to work (Maciel & Marques, 2008; Neves, 2013; Oliveira & Amâncio, 2002). Thus, women are more likely to have precarious jobs, with low income, as well as being more vulnerable to unemployment (Cerdeira, 2009). The idea that men are expected to be the main breadwinner and women retain the main responsibility for care and domestic work is rooted in employers, particularly in companies that implement a gender-based division of labor opportunities (Maciel & Marques, 2008).

Family dimension

Regarding the family context, the differences between gender roles are quite evident. Men's contribution to domestic work is traditionally placed in second place as the role of aid to women, since these tasks are not presented as a duty or a shared responsibility (Nuncio, 2008). The same is true for children. Although maternity and paternity leave can already be shared by the couple (in Portugal, this right is protected in Article 36 of Law 99/03 of 27/08), women are the ones who traditionally assume the role of childcare since birth, given the prevailing stereotypes that this duty belongs to them and that men, when assuming such role, have their masculinity called into question (Nuncio, 2008).

While men are generally seen as the breadwinners and principal figure of authority, women still bear the main responsibility for guaranteeing the family care and well-being, thus restricting their gender role. When they choose to hold positions of great responsibility in the labor market, women tend to avoid marriage, in order to achieve a greater control and better management of their daily lives in favor of their professional activity. Generally, married women with children represent a minority in these top positions (Cardoso & Loureiro 2008). Although this reality is changing in western society towards a greater gender equality in opportunities and responsibilities, there is still a long way to go within families, work contexts and in educational (formal and informal) contexts.

Educational dimension

Despite access to education being protected in art. 26 of the Universal Declaration of Human Rights of 1948, in many realities, schools are not yet accessible to all and educational opportunities differ between men and women. In Portugal, the compulsory formal education, does not necessarily mean that everyone has the same opportunities.

Since school is one of the most significant contexts of socialization, it plays a decisive role in the education of children and young people by conveying concepts, values ​​and practices, which can influence expectations and equality of opportunities in terms of training and professional paths.

If children and young people are educated to recognize the value of equality, gender differences will tend to decrease. Changes have already occurred at this level, although gender differences are still evident as can be seen, as an example, in the following dimensions.

The areas of knowledge are hierarchical in our society, with the exact sciences occupying more relevant places than languages, social and human sciences. The former are essentially associated with men, who are supposed to have characteristics such as rationality, objectivity, coldness and impersonality; (Saavedra, 2005, cited by Nogueira & Saavedra, 2007). In addition, the second group is mainly associated with women, because of the emotionality, subjectivity, expressiveness and sensitivity attributed to them. In respect to this differentiation, school textbooks have their own contribution through the massive presentation of male elements associated to science areas, which lead women to grow embedded in the idea that these areas are particularly reserved for males (Saavedra, 2005, cited by Carvalho, 2010). On the other hand, boys and young men who evidence good results in reading and writing are frequently compared to girls and young women given their attributes in stereopytically feminine domains, which involve more reflection than action (Gilbert & Gilbert, 1998, quoted by Nogueira & Saavedra, 2007; Saavedra, 2005, quoted by Carvalho, 2010).

Nevertheless, in the Portuguese reality it has been observed that boys and young men do not always obtain the best academic results. In higher education, in particular, it is noted that the relation male/female is 4:7, contrary to the European average. According to Nogueira and Saavedra (2007), courses in the fields of medicine, agriculture, forestry and fisheries, which, in general, have a higher male frequency, have a significant female presence in Portugal - 61% and 63.5% respectively. However, in areas such as civil engineering, electronics and electricity the female presence is still significantly reduced, 30.1%, 16.3% and 11.2%, respectively.

Finally, the way male and female students identify with different professions make career choices often mirror social expectations, repressing some preferences and exalting others (Lorenzi-Cioldi, 1988, quoted by Nogueira & Saavedra, 2007).

Despite the unquestionable changes in this field, as previously discussed, for gender equality to be a reality it is fundamental to intervene from early on and throughout life, in individuals’ contexts of socialization. According to Vega Caro (2012), prompting a new gender culture implies that a new view on social relations is built, based on equality. Bearing this concern in mind, Catarina Marcelino, the current Portuguese Secretary of State for Citizenship and Equality, announced the most recent strategy of Education for Citizenship. Beginning in the academic year 2017-18, topics related to the promotion of equality, the fight against violence and gender stereotypes will be included in the schools’ curriculum, from pre-school to Grade12. "This proposal aims to bring to the classrooms, conducted by educational professionals, the topic of human rights and gender stereotypes, including issues of violence and inequality, " (Marcelino, 2017, cited by Faria, 2017).

If in basic and secondary education, addressing these issues is essential for promoting a culture based on equality and intolerance towards gender violence and discrimination, in higher education this is mandatory, particularly in courses that seek to foster human development and ensure the fulfillment of human rights, as is the case of the Social Education course in the School of Education from Porto Polytechnic.

Gender issues in curricular context

First of all, a brief framework on Social Education needs to be made. As stated by Timóteo and Bertão (2012, p. 16), being emancipatory and transformative, social education shares the "vision of a more egalitarian, supportive, inclusive and democratic world, based on the sociocritical paradigm and the view of human beings as capable of looking at themselves and at the world in a critical and informed way and able to intervene by following intelligible and conscious values”.

Based on this vision, several curricular units of the Social Education course from ESE/IPP reflect the concern to analyze, discuss and problematize a variety of value themes, through the use of different teaching-learning methodologies. In the curricular unit of Personal and Social Education, in the second year, students have the opportunity to discuss and analyze various topics related to their academic education, as well as their role as citizens committed to change for a fairer and more equal society. It is, therefore, a curricular unit that challenges not only students to a theoretical-conceptual reflection, which occurs mainly in theoretical and theoretical-practical lessons, but also to a experiential work, developed in practical lessons around value-based issues that guide their attitudes and behavior (Veiga & Monteiro, 2013).

Concerning the (in)equalities among social relations, Vega Caro (2012) argues that new models, methodologies and practices should be considered. In that regard, in practical lessons, the main teaching-learning methodology used is Jacob Levi Moreno's Sociodrama (eg, Moreno, 1997/1946, Veiga, 2009; Veiga, 2014). This methodology, through its structure, dynamics and principles, allows exploring the multiplicity and complexity of issues involved in this reality in a creative and experiential way.

An educational experience...

Lessons from the Personal and Social Education curricular unit follow the principles, assumptions and praxis explained by Moreno (cf. Moreno, 1997/1946; Veiga, 2009; Veiga, 2014). They take place in large classrooms that enable the building of the Sociodramatic setting, and generally focus on students’ issues, concerns and/or needs found in every moment of their education, as well as on their school and social experience. In these lessons, the intent is to work, above all, on collective issues and roles and avoiding, as Blatner (2006) and Veiga (2009, 2014) argue, the exploitation of more private roles. The sociodramatic dynamic result of the interplay between protagonist⁸ and auxiliary egos⁹, directed by professor-director¹⁰ who suggests a set of scenes and techniques to explore the theme in question and the development of spontaneity in the protagonist (Veiga, 2009, 2014). In one lesson of this curricular unit within a class composed just by women, the warm-up phase¹¹ focused on gender issues, when a student spoke about a video in which an interviewer asked opinion about Hillary Clinton as a candidate for the presidency of the United States of America, and one lady replied that she did not agree with her application, because the presidency is a place for men. This has triggered an intense debate on the different views of women’s roles in society and issues about gender equality and social justice. Questions raised in this debate included: "What is the current situation of gender equality? What prevents / hinders gender equality? Are men fighting against women's power? Or are women who condition other women who want to move forward?" While recognizing the evolution of women’s role over time, students argue that stereotypes and prejudices embedded in society, revealed both by men and women themselves, not infrequently lead to discriminatory attitudes towards women.

Following this first phase, the dramatization¹² phase began, and by the request of the professor-director, a sculpture of the contemporary woman was held on the stage¹³. The group enthusiastically got involved in the task, which resulted in the following representation (Figure I):

The spokeswoman for the group explains the sculpture, noting that two women were placed ahead, representing those who managed to break stereotypes and barriers and achieve success; behind them were three women fighting for their ideals of equality to achieve what men have almost for granted, but have restrictions (fears, prejudices, role expectations, power differences) represented by the hands of the five women who grab them. These represent some contemporary women who do not understand the need to fight for gender equality, or who by not believing in this possibility, prevent others from following their dreams and achieving what they want; and finally, four women passive towards the fight that was happening right in front of their eyes were at the back of the group. When reflecting about this activity, each student was able to tell her story, from the standpoint of the role assumed, evidencing: first, the struggles they faced, the stereotypes they broke and the incentives/support they received; the second, above all, spoke of their desire to move forward, and some achievements they already achieved, but also the intensity and pressure of the restrictions, represented by the hands that grip them, many of them belonging to women who prevent themselves from going further and achieve autonomy and empowerment (Figure II).

The women representing the restrictions reveal a conservative view, in which men are still expected to have the power and women retain the main responsibility for childcare and housework. In these reflection still emerges gender stereotypes related to male supremacy in labor and intellectual issues, which explains why power positions are attributed to man. "I took the place of some women’s conscience that tell them they cannot be better, preventing them to move forward and transmitting this idea to women trying to move forward" (Written reflection by one of the protagonists). From the group of passive women, one says that this position is due to the fact that this fight has no interest to her, because she feels comfortable, other justifies she is conformed and accommodated to the idea that, regardless of what is done, equality is an unreality. The third group assumes the critical discourse regarding women who desire change, legitimizing a stereotypical view of the men role.

In the last sculpture, students climbed to a chair, joined by a rope representing union and equality among all (Figure III).

From this place, women in the group express their feelings of victory, because they have achieved equal rights, are empowered and autonomous (Figure IV).

Nevertheless, they point out that this is utopia, very difficult to achieve. Still on the chairs, each group member was asked to state how they could contribute to gender equality in their life contexts.

In the comments14 phase, the progress made in this field was shown, nonetheless gender stereotypes still prevail in society, and some women seem to hamper or condition the struggle for equality in gender rights and gender obligations. In the condition of citizens and professionals, students recognize that it is their duty to be aware of their social representations, preventing their own stereotypes to condition their role as women and professionals in practice. They are more aware of the importance, and also difficulty, of challenging stereotypes and prejudices in their daily lives, but also of the required urgency, if they are looking for a fairer and more egalitarian future. As future social educators, students say that they feel particularly committed to the effort for deconstructing prejudices and stereotypes of themselves and others, so that the opportunity is given to each one to be seen as unique, with a unique course and history, despite being part of a group with a collective identity.

Written reflection of a student

"The ongoing reflections within the curricular unit of Personal and Social Education, as well as the confrontation with practical situations that we will deal in the future, help us to develop attitudes more adjusted to the contexts in question. Gender stereotypes, racism, xenophobia, among other biased beliefs, are serious obstacles to the development of more just and equitable societies. Often what is at stake is the desire for power, imposing ways of being, living and looking at the reality. This can be a reality that happens in the daily life of each one, but also in the practices of so many professionals. How many social work professionals have we met endorsing inferiority beliefs about their interlocutors and other cultures? Respecting and understanding that what is unfamiliar is not necessarily bad, is crucial to cultivate an empathetic, honest and caring attitude towards others (...). Further, an essential step for a personal change includes learning to get a better understanding of ourselves and this can only happen when we face real situations and discuss these issues within the group"

"Social educators, as professionals whose practice is based on relationships and proximity, act as promoters of equality, in particular between genders, supporting individuals in the various social dimensions and spheres.

In the field of labor market, it would be necessary to raise employers’ awareness towards the provision of equal opportunities between men and women. For the intervention to be more effective, it is also important to raise awareness of genders’ equal needs in terms of the economic subsistence, the rights to work and responsibilities within the family.

In the family field, the social educator can work with family members so that everyone can collaborate in the same tasks and participate in family decisions, sharing the same rights, namely for leisure, work and education, among others. Social educators should also encourage parents to transmit these values ​​to their children, so that they can adopt them in school and throughout their lives.

In the school field, professionals can intervene with the school community through awareness raising actions aimed to demystify stereotypes and change discriminatory practices. "

Final considerations

Human beings develop and build their gender identity in the relationships with others (real or symbolic) present in their different socialization contexts and instances.

Being one of the main instances of socialization for children and young people, schools should be concerned not only with students’ academic formation, but also with their overall education. Preparing students to become active, participatory, responsible and creative citizens - who have a critical and transformative role in the reality they participate and are co-responsible - is a guarantee that a more just and egalitarian society can be established. In this sense, schools should introduce practices seeking to educate students about diversity and equality values, respect for rights and individual and collective freedoms.

In everyday school and/or in the curricular context, issues of gender (in)equality can and should be, since early ages, addressed, worked out and reflected. The educational experience described in this paper showed how, through Sociodrama, students could, in an active and experiential way, address the role of women in society, reflecting on the restrictions - stereotypes, prejudices and discriminatory attitudes - that prevent them from achieving the desired equality. With each other, in the here-and-now, students were able to share, debate and collectively build knowledge about this theme. More aware of what can contribute to gender (in)equality - in particular the contaminating and undesirable effects of the numerous gender stereotypes – students have been able to commit to the change that needs to happen, in society, in reality and also in each individual.

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Chapter 3

Law

Deinstitutionalization – How?

Maria Luísa Salazar

Faculty of Law, OPorto University

Abstract

The main focus of this paper is on Portugal’s recently revised child protection system, which has phased out the institutional framework in favour of a more personalized system which offers children a familiar environment. In fact, some public policies have been amended in this regard, aiming to apply welfare measures directly to the family and avoid its separation. It is imperative to think about how these measures are implemented and whether they need to be renewed or restructured in a way that will further their goal: to keep the child out of danger. A major step was taken with the introduction of Law 142/2015 on September 8th, which began a process of deinstitutionalization. While the legal framework has been put into practice, many practical changes remain to be executed in order to implement a friendlier and truly protective care system for endangered children and youth.

Keywords: Foster Care; Child Protective Services; Institutionalization; Foster Families

There is a house built out of stone

Wooden floors, walls and window sills

Tables and chairs worn by all of the dust

This is a place where I don't feel alone

This is a place where I feel at home

To build a Home, The Cinematic Orchestra

Introduction

Institutionalization emerged as a response of the public system to the needs of children and youngsters in danger based only on effective welfarism. However, recently, more and more European countries have been reducing these institutions and, consequently, the number of institutionalized children, focusing, instead, on their growth inside the family environment or, if that’s not possible, in a care home specialized in children’s needs.

In Portugal, in the fields of politics, law and social services, there’s a growing focus on children’s rights, either in the family environment or in alternative care.

Continuously, in Portugal and abroad, the withdrawal of the institutionalization option is advocated in child protective services. As stated in the United Nations General Assembly Resolution A/RES/64/142, 24th February 2010, the withdrawal of the child from its family environment should be the last resort and, whenever possible, a temporary measure, for the briefest time possible.

The recent changes in the law indicate a turning point in children protective services leaning towards a deinstitutionalization, shown by Law No. 142/2015, December 8th, which changed the Protection of Children and Youth in Danger Law [Lei de Protecção de Crianças e Jovens em Perigo] (Law No. 147/99, September 1st, from now on LPCJP). The changes intend to work on three cores of deinstitutionalization: reduction in the number of children and youngsters that are fostered; adjustment of the residential responses; and focus on family care – matters that we wish to analyze.

Consequently, the system has opted for familiarization of foster care, in other words, the focus of Government and society is to give the children an opportunity to experience a truly welcoming and personalized environment that they can call Home. After all, it’s in our Home that we grow and learn to be a Home.

Child protective services – brief approach

Child protective services rely on the society’s responsibility to protect and promote children’s rights.

The system follows the subsidiarity principle (see article 4 point k), which implies that the interventions should rest with entities in charge of children and youth matters, followed by the Child Protection Committee [Comissão de Protecção de Crianças e Jovens] (from now on, CPCJ) and, lastly, the Courtroom.

The intervention of these three entities should be precocious and minimal, executed only when the danger of the situation is well known. It should be, also, executed by the institution whose action is crucial to the uphold of the child’s rights and protection, as it says in article 4 c) and d) of LPCJP. In LPCJP, article 4, point e), the intervention should be adapted to the situation of danger that the child is in at the moment of the decision and can only interfere in their life and the family’s life when strictly necessary for that purpose.

Difference between risk and danger

It is important to distinguish between the concepts of risk and danger. The first concept is about the possibility of ill-treatment of the child and is wider than the concept of danger.

As the National Committee for the Promotion of Children’s Rights [Comissão Nacional de Promoção dos Direitos e Protecção das Crianças e Jovens] says, “unsafe situations imply a potential danger for the child’s rights, not reaching the high level of probability of occurrence that the legal concept of danger entails” (CNPDPCJ, 2017). Maintenance or increase of the risk factors may, in some circumstances, lead to dangerous situations, in the absence of protective or compensatory factors.

However, not all dangerous situations come necessarily from a previous risk situation. They can arise from an acute crisis. The distinction between risk and danger determines the various levels of responsibility and entitlement in our Child Protective System [Sistema de Promoção e Proteção da Infância e Juventude].

In unsafe situations, the intervention is based on efforts to overcome the given reality, with the sole focus on primary and secondary prevention from dangerous situations, through policies, strategies and integrative actions destined for the general population or specific family and children groups in vulnerable situations. Normally, risk protection is the responsibility of the entities in charge of Children and Youth matters.

On the other hand, article 3 of LPCJP says that the intervention to protect the rights of the child in danger happens when the parents or the legal guardian endangers the child’s security, health, education or development, or whenever that danger results from the actions or inactions of a third party, or of the actual child or youngster, without the ones in charge doing anything to remove the danger.

The 2nd point from the 3rd article of LPCJP says that the child or youngster is in danger when: “is abandoned or left to cater for themselves; is ill-treated physically or mentally or sexually abused; doesn’t get proper care or affection appropriate for their age; is in the care of a third party, during a period of time whereby a bond was formed with that third party in the absence of the parents performing their parental duties; is forced to do activities or excessive and inadequate work for their age, dignity and personal situation or harmful to their education and development; is exposed, directly or indirectly, to certain behaviors that greatly affect their security or emotional balance; has behaviors or pursues activities or vices that gravely affect their health, security, education and development without the parents or the legal guardian opposing them.

Nature of the measures for protection of children’s rights

In the face of danger, CPCJ and the Court apply measures to protect children and youngsters and to defend their rights. Such measures aim to: remove them from danger, give them the necessary conditions to promote their security, health, education, wellbeing and general development, and ensure their physical and phycological recovery from the exploitation or abuse that they were victims to (article 34 from LPCJP).

As it says in article 35 of LPCJP, there are two different types of protective measures depending on the nature of the danger: the measures executed in the natural environment and the measures executed in a placement system. More than focusing on the type of danger, the distinction refers, above all, to the location of the danger. If this has its origin in family unit and, due to its gravity, demands the removal of the child, it is necessary for the child or youngster to be put into alternative care.

As shall be seen, the removal from the natural environment has to behold certain principles, for example the child’s best interest. This concept is legally undetermined therefore it should be decided according to the circumstances. Within the child protective services, it is important to continue to pursue meaningful affectionate relationships in order to ensure the child’s best interest (article 4, point a) of LPCJP).

Examples of measures taking place in the child’s natural environment are: support given to the parents, support given to a relative, placement in a foster family or support for the youngster’s independence (article 35 LPCJP). Such measures are included in the decree no. 12/2008, January 17th, not expressly revoked by the 2015 revision.

Supporting parents involves giving or reinforcing the necessary skills for a responsible parenting and a proper fulfilment of the child’s needs. Support given to a relative or placement in a foster family are based on taking care of the child in an affectionate and responsible way in order for him to acquire the affectionate, physical, phycological, educational and social skills necessary for his age that will allow him, once the timing of the measure is complete, to pursue his integral development, preferably by the parents or on his own (article 16 from Decree 12/2008, January 17th).

Therefore, the Portuguese child protective system defends staying with the original family, responsible parenting and continual profound phycological relationships as principles for the integral development of the child (see article 4 from LPCJP). The majority of measures to protect and promote the child’s rights are confirmed and constant in article 35 from LPCJP, with special incidence on measures supporting parents over measures based on fostering (CASA, 2015, p.12).

Despite that fact, an alarming number came up of children and youngsters that had measures applied in their natural environment prior to their first foster in 2015: 49,5% of children and youngsters (CASA, 2015, p.31). This number may reflect a possible inadequacy, infectiveness or lateness of the measures initially applied in the natural environment, consequently compromising the best interest of the child or youngster. Within this scope, more persistent and, above all, prompt work is required from the entities in charge of children and youth matters as they are the forefront response in protecting and promoting children’s rights.

On the other hand, placement measures are based on foster families and foster care and apply when the withdrawal of the child or youngster from the family unit is necessary. Given the gravity of the situation and the danger of remaining in the family unit, the child’s security, health, education and integral development is considered at risk.

The danger situation and the withdrawal of the family unit

The protection right applies when a child is in danger due to his unbalanced and inadequate reality. The objective is that their physical, moral and phycological development occurs in a harmonious way and in an affective, educational and responsible familiar environment, without abrupt changes. The danger situations don’t necessarily result in the placement in alternative care, as referred. In case the withdrawal from the family unit is vital for the child’s protection, the measure applied should have as minimal impact as possible so that the emotional stability of the child is preserved, as shall be seen.

As stated in CASA Report (2015, p. 17), there’s a constant variation of the number of children and youngsters in foster care in the latest years, with a tendency for the number of signalizations of the dangerous situations lacking foster care to stabilize, and consequently the capacity of the network. 8600 children and youngsters were in a foster situation (more 130 than last year) and 2612 terminated their foster situation. In 2014, more than 179 children and youngsters terminated their foster situations.

The analysis of this data tells us that Portugal still has a long way to go in the deinstitutionalization path. This process is not only about the placement of children and youngsters in foster care, but also about the conditions provided to the children, for example, the prolonged stay of children and youngsters in foster situations, which brings great concern. Within this scope, we can question how the integration outside the institution takes place, that is, what work occurs with parents when the child goes into foster care. This matter should be profoundly studied because the construction of a foster system that calls itself temporary is of little use if there is no real commitment to family reunion.

The placement of the child or youngster in foster care is, on its own, destabilizing. On the other hand, the prolonged stay in alternative care is an aggravating factor that should be avoided by the system. If working with family before danger takes place is possible, it should also be possible to capacitate the family after the removal of the child. The continuity of the child in the foster system until adulthood, in the hope of going back to the family unit, should urgently be worked upon.

As reinforced by the United Nations General Assembly Resolution A/RES/64/142, 24th February 2010, the promotion of parental care, the prevention of the family separation and the promotion of the family reunion are defended if it is in the child’s best interest (FRA, 2016). The foster measures aim to be temporary because the ultimate objective is always the future integration of the child in a family unit.

Family care should be the preferable form of alternative care in order to ensure the effective protection and integral development of the child. On the other hand, foster of a non-familiar nature “should be restricted to cases in which the circumstances are specifically adequate, necessary and constructive to the child in question and their best interest”, as defined by UN (2010, 4). The protective system now upholds that a child, especially in its first years, should be integrated in a familiar and individualized context, where it can establish strong relationships, as defended by Jesus Palacios (2015, July 13th). In 2015, about 96,5% of children and youngsters taken in by the foster system were in social structures of institutional nature (CASA, 2015), which means that there is a long way to go at a gradual pace.

Increasingly, the role of important measures and policies is acknowledged to avoid the removal of the child or youngster from the family unit, like for example the reinforcement of financial support from the entities that have the first line response in child and youth matters, the increase of responses in the community based on positive parental care and, above all, the promotion of social measures, job creation and harmonization of work with family life.

As also referred to in the General Comment no. 14 of the Children’s Rights Committee [Comentário Geral no. 14 do Comité dos Direitos da Criança] CRC/C/GC/14, 29th May 2013, due to the grave impact the separation from the parents has on the child, it should be a last resort, in other words, when a danger situation is established or in case other less intrusive measures don’t apply. Where the separation is not immediately necessary, the Government should support the parents in their parental responsibilities and capacitate them to take care of the child.

Socioeconomic reasons don’t constitute valid justification for the separation of the child from its parents. In this regard, in the process TEDH, Wallová e Walla c. Czech Republic, the European Court of Human Rights considered that the removal of the children from their family unit and the placement in two different residencies, due to the absence of a convenient home, would be an inadequate option for the situation at hand. The reasons for the children’s institutionalization were considered insufficient and therefore the supreme entities and Czechoslovak authorities could have resorted to less drastic options to solve the problem. In this case, the child’s best interest wasn’t taken into account. Also, regarding the placement of children in alternative care, see process TEDH, Saviny C. Ucraine nr. 39948/06, 18th December 2008.

As declared in the Children’s Rights Convention [Convenção dos Direitos da Criança], the child has the right to express their opinion freely about matters which affect them and see that opinion taken into consideration (article 12.º from the Convention). Only after this right is upheld will the decision take place regarding the child’s best interest. Other international documents fall within this scope, like the Charter of Fundamental Rights, which states that children should express their opinion freely and that opinion should be taken into consideration in matters that affect the child, with regard to his age and maturity (article 24, no. 1 from the diploma). In Portugal, point j) of article 4 from the Protection of Children and Youth in Danger Law [Lei de Protecção de Crianças e Jovens em Perigo], declares the fundamental right of being heard and participating, where the child or youngster, individually or accompanied by the parents or a trusted third party, as well as the parents or legal guardian, have the right to be heard and participate in the actions and definition of the promotion and protection of the child’s rights measures.

The change in the Residential Foster Care reality

On the 1st October 2015, with Law no. 142/2015, September 8th, institutionalized foster care changed its name to residential foster care. As stated in the newest version of article 49 from LPCJP, residential foster care consists of placing a child or youngster in the care of an entity which possesses the facilities, resources and permanent human resources, trained and adequately dimensioned, to ensure the fulfilment of the child’s needs.

The now called ‘residentialization’ [residencialização] was transferred to a subsidiary plan, and priority given to the family placement measure, which features in point e) from article 35 of LPCJ. In truth, the Portuguese system believes that every child and youngster need bonding as a way to be protected and to develop. Sometimes, the residential foster care measure becomes questionable regarding the protection it is supposed to offer.

Subsequently, with Law no. 142/2015, December 8th, the distinction between the institutions based on the type of protective measure disappeared (former Temporary Foster Homes [Casas de Acolhimento Temporário – CAT]) and Youth Homes [Lares de Infância e Juventude – LIJ]) and only Foster Homes remain. These comply with specific socio-educational intervention models appropriate for children and youngsters, with special relevance in point no. 3 of article 50 of LPCJP.

Foster Homes are organized based on the response they offer:

Emergency situations;

Response to specific problems and educational and therapeutic needs of the child or youngster;

Autonomous apartments for the support and promotion of youngsters’ independence.

As stated in article 53 from LPCJP, Foster Homes are organized in units which favor an affectionate relationship similar to the family one, a personalized daily life and the integration in the community.

Despite the alterations brought about by Law no. 142/2015, September 8th, it becomes necessary to put these changes into effect through the deployment of therapeutic intervention models and the introduction of structures following familiar based models that allow a more specialized and adequate response to the emotional and behavioral particularities.

By definition, the therapeutic foster equals the “residential foster of children and youngsters who aspire to have an effective part in the internal and emotional change, as well as behavioral and social” (Casa Pia de Lisboa, 2015, p.15), with the focus on repairing the ill-treatment and negligence that lead to their placement in the foster system.

In other words, the objective is to “normalize” the Foster Homes and make them familiar places to the children and youngsters who feel and are in fact protected. Consequently, problems like sibling separation, changing foster homes or the tight visiting schedules disappear; being crucial to create the conditions that guarantee an integral development and well being of the child or youngster. Small details like the simple identification of the vans destined to transport the children between the foster home and the school are matters worth rethinking about in the “normalization” process of the child’s life. We value the example given by Associação Mundos de Vida, from Famalicão, who considered the identification of its vans an unnecessary element, removing it for the protection of the personal identity and dignity of the children.

Furthermore, in the child’s best interest and allowed by the judicial bodies, the right to maintain contact with the parents should be respected. As stated in point no. 3 of article 24 from the Charter of Fundamental Rights of the European Union, all children have the right to maintain regular personal relationships and direct contact with both parents, except if that goes against the child’s best interest. Within this scope, we remember process TEDH Mustafa e armağan Akin c. Turkey no. 4692/03, 2010, in which the European Court of Human Rights considered that separating two brothers would be a violation of the right to a family life because not only did it prevent the brothers from seeing each other, it also prevented the father from being with the children at the same time. Despite this process being about parental responsibility, the principle of non-separation of siblings and the maintenance of contact between the children and the parents is evidently highlighted, applied to the alternative care situations.

Besides the contact with the parents, one should not forget strong phycological relationships between the child and other people. The mitigation of the institutionalization effect is also important in this case.

In view of the above, it is imperative to reorganize the institutional dynamics of some children and youth social structures in Portugal. The inflexibility of visiting schedules, sibling separation and the placement of children and youngsters in residencies far away from the family home address are obstacles to their right established in the Children’s Rights Convention [Convenção dos Direitos da Criança], article 9 (“The State respects the right of the child separated from one or both parents to maintain regular personal relationships and direct contact with both, except if it is against the child’s best interest”).

For this purpose, structural changes are in essential, especially focused on the training of social structures Technical Directors, superior technicians, education and assistant teams, who are required to be strong and stable, both emotionally and physically, so that a specialized and therapeutic intervention is achieved close to the children and youngsters who, due to not fulfilling the necessary conditions to be placed in a foster home, need a Home to protect them. Besides the professionals’ training, it is imperative that physical conditions of social structures are created for therapeutic shelter (it should be enough for a small number of children and youngsters) and support given to educational teams, with special focus on supervision and consultancy.

Foster Families: contribution of Law no. 142/2015, September 8th

As stated in CASA Report, in 2015 only 303 children and youngsters were placed in foster families, showing a predominant number of responses of prolonged shelter, with 5408 (62%) of children and youngsters in the above mentioned Youth Homes (CASA, 2015, p.34).

In the new legal regime, family foster care is finally seen as the preferable measure for children up to 6 years old, except when the specific situation of the unprotected child is considered to be subject of residential placement or when family foster care is not an option (see point no. 4 of article 46 of LPCJP).

According to the law’s latest revision, foster care consists of the placement of the child or youngster in the care of a trusted individual or family, who is able to offer the child or youngster integration in the family unit and proper care to their needs and well-being, as well as the necessary education to their integral development. The application of this measure takes place when the future integration of the child or youngster in a family is predictable or, if it is not possible, the preparation of the child or youngster for independent life (article 46 of LPCJP).

Some practical questions regarding the implementation of the renewed family foster care system arise.

As previously mentioned, Portugal still doesn’t have much experience in family foster care, therefore these families reflect a very small number (CASA, 2015, p. 34). An effective plan of action which includes the attraction of foster families, who must be up for the challenge, becomes imperative. Raising society’s awareness with regard to family foster care and the creation of family subsidies become necessary in this scope.

Similar to other forms of alternative care, we should not forget the importance of the maintenance of contact between the child and the parents, the non-separation of siblings and the work taking place for family reunion when it is intended. In order for these rights to be ensured, the Government should create measures and institutions that promote these responses.

We admit that sheltering children and youngsters who experienced dangerous situation in the family environment might not be an easy task. Therefore, it is the State’s responsibility to make a thorough selection of and give solid training to foster families for children and youngsters scarred by their life’s story.

It is imperative that foster families are mentally sane, that they recognize the child’s specific needs and are effectively willing to create bonds, in other words, create a profound relationship that provides the child the protection of a family environment. In other words, the ideal candidates are families who take in the child or youngster, look after, protect, nurture and encourage them in a happy, loving and understanding environment. Thus, the families must be trained so that they can achieve this goal and effectively protect the child or youngster. Let’s face it – not all families have the conditions to do this.

Just as important as training the families, is accompanying and supporting them. It is vital that foster families understand the foster notion, the child’s needs and the shelter arrangement and duration. A child or youngster may be taken in for a short period of time, aiming for a fast biological family recovery, or can be sheltered until adulthood, in case the situation where no biological family recovery occurred or the child or youngster couldn’t be adopted.

As odd as it may sound initially, the foster family is required to create bonds, love, accompany and eventually let go of the child. It is hard to say goodbye, we all know. However, both child and family should be informed and accompanied, considering that the objective is to protect the child from the dangerous situation and hope that, sooner or later, that situation disappears. This potential goodbye reminds me of an excerpt from the book ‘The Little Prince’, by Saint-Exupéry, in which the character says goodbye to the fox: “Go and look again at the roses. You will now understand that yours is unique in the whole world. And now here is my secret, a very simple secret: It is only with the heart that one can see rightly; what is essential is invisible to the eye. It is the time you have wasted on your rose that makes your rose so important”.

We question, finally, the possibility of the foster family adopting the child in the future, in the event of that being in the child’s best interest. However, doubts emerge regarding this situation in case some families use this alternative as a means of getting around the adoption system. This is a matter that deserves further debate.

Other questions arise regarding Decree no. 11/2008, January 17th, which establishes the former LPCJP, October 1st 2016, foster family regime. We await the regulation for this new Foster Family reality.

Conclusions

Despite the legislative effort in 2015, the path to deinstitutionalization in the foster system for children and youth at risk should continue to be worked upon, especially regarding the novelties brought about by Law no. 142/2015, September 8th.

The first course of action is the reduction of the number of children and youngsters taken in by the system, which implicates, firstly, a growing responsibility of society in protecting children and youth, especially the entities in charge of infancy and youth matters. In order to achieve an effective reduction of the risk cases, the training of technicians and social workers from the first line entities becomes crucial so that timely detection of dangerous situations is possible.

When the dangerous situation is inevitable, second line entities (CPCJ) should put into practice measures designed for the natural environment. I question whether the execution of these measures should be the subject of restructuring or renewal because the referred to numbers, in my point of view, reveal the inefficacy of the measures applied in the natural environment.

On the other hand, the foster system for children and youngsters should be more and more seen as an exclusively temporary solution that aims to reintegrate the child into a familiar environment. Given the growing recognition of the importance of family bonds for younger children, the effort in personalization and familiarization is vital, which entails the adequacy of residential responses to the specific needs of the child or youngster and the focus on family foster system, the regulation of which we eagerly await.

As explained above, the deinstitutionalization of the foster system for children and youngsters who need a place where they can learn to be Home and create bonds is possible.

References

I. Carta dos Direitos Fundamentais, CIDADE 2000

II. ISS, I.P. - Instituto de Segurança Social, I.P., CASA – Relatório de Situação de Acolhimento, 2015, Instituto da Segurança Social, IP

III. Casa Pia Lisboa, (2015) Acolhimento Terapêutico: Pistas de intervenção para profissionais,  http://www.casapia.pt/wa_files/Acolhimento_20Terapeutico_202015.pdf 

IV. CNPDPCJ (2017), A Criança em Risco. 10th June 2017, http://www.cnpcjr.pt/left.asp?13.02

V. Convenção dos Direitos da Criança, CIDADE 1989

VI. Decree no. 12/2008, January 17th, Promoção e Proteção das Crianças e Jovens em Perigo em Meio Natural de Vida

VII. FRA - European Union Agency for Human Rights (2015), Manual de Legislação europeia sobre os Direitos da Criança

VIII. Lei de Proteção de Crianças e Jovens em Perigo, approved by Law no. 147/99, September 1st, altered by Law no. 142/2015, September 8th

IX. UN, General Assembly, Diretrizes sobre a prestação de Cuidados Alternativos às Crianças, 24 February 2010, A/RES/64/142, retrieved from: https://www.unicef.org/protection/alternative_care_Guidelines-English.pdf

X. Palacios, Jesus in Jornal Público (2015, July 13th), https://www.publico.pt/2015/07/13/sociedade/noticia/a-ideia-da-nao-vinculacao-e-monstruosa-para-a-especie-humana-1701797

XI. UN, General comment No. 14 (2013) on the right of the child to have his or her best interests taken as a primary consideration, retrieved from http://www2.ohchr.org/English/bodies/crc/docs/GC/CRC_C_GC_14_ENG.pdf

XII. TEDH Process, Wallová e Walla c. Czech Republic, no. 23848/04, 26th October 2006, retrieved from: http://hudoc.echr.coe.int/eng#{%22itemid%22:[%22001-77713%22

XIII. TEDH Process, Mustafa e Armağan Akin c. Turkey, no. 4694/03, 2010, retrieved from: http://hudoc.echr.coe.int/eng#{%22itemid%22:[%22001-97957%22

Chapter 4

Nutrition

Nutritional Diagnosis for Educative Intervention in a Full-Time Private School

Maria Marta Amancio Amorim

Nutritionist, PhD. Researcher of CEMRI/Lisbon, Professor at Center UNA - Brazil

Rejane Graça dos Santos

Nutritionist. Specialist in Nutrition Education

Alessandra Hugo de Souza

Nutritionist. Specialist in Geriatric Nutrition

Adriana Keller Coelho

Nutritionist. Master in Health Science. Professor at Pontificial Catholic University of Minas Gerais, Brazil

Abstract

It is unquestionable the importance of an adequate healthy eating for assurance the correct growth and development of preschoolers and schoolchildren. The average consume of the lunch served to 79 schoolchildren with ages from 1 to 12 years old in a full time private school in Belo Horizonte/MG was evaluated. Direct weighing of the preparations, leftovers and tailings was used. The daily average meal intake of 252.39g and 58.76ml juice, 466 ± 113.84 kcal, reaches the energetic needs only for 1 to 3 years old preschoolers (36%). For 4 to 6 years old children (32%), 7 to 10 (26%) and 11 to 12 (19%) the intake was lower than 35%. It is recommended that food and nutritional education be part of the curriculum of the school in a contextualized and systemic way, taking into account all the aspects involved in the formation of habits and attitudes of pupils referring to the act of eating.

Keywords: Schoolchildren, self-service lunch, food consumption, food interventions

Introduction

Learning and attention changes, an increased number of school repetitions, specific nutritional deficiencies or those resulting from excessive eating, such as overweight and obesity and the appearance of chronic degenerative diseases are the main consequences of an inadequate diet in preschoolers and schoolchildren (Danelon, Danelon & Silva, 2006)

In preschool, between first and sixth school year, occurs the reduction of the rate of growth, reduction of appetite and consequently the children refuse or request a particular food at each meal. The schoolchildren, children from 7 to 12 years old, execute intense physical activities besides school activities, making higher their energetic demand. Taking into account these specificities, the nutritional requirements must be met both at home and at a half or full time school (Vitolo, 2008).

Preschoolers and schoolchildren that study full time, spend most of the day in school environment, so the teachers must guide them to put in practice a healthy eating. This way full time school supports the implementation of health programs, especially nutritional and food education in all study cycles.

In public and private schools questions related to food and diet are addressed in the work proposals for natural sciences area and transversal themes, mostly environment and health education described at national curricular parameters. These programs must consist in actives, ludic and interactive processes, developed in classroom and at the meal moment in order to promote changes in attitudes and eating practices (Brasil, 1997; Brasil, 1999).

In this environment, the educator, using data from the reality of the school obtained in the nutritional diagnosis and strategies of constructive teaching, provides the student with an understanding of everyday issues related to food and health. Therefore, the objective of this study was to evaluate the adequacy of the lunch consumed by the students and to propose topics to be discussed in the educational interventions for the students of a private full time school in Belo Horizonte.

METHODS AND MATERIALS

This study was carried out between 2009 April and July in full time private school cafeteria in Belo Horizonte. In the cafeteria the following meals are served: breakfast, collation, lunch, afternoon snack and dinner for 79 children, 47 girls and 32 boys with ages ranging between 1 to 12 years old.

The direct weighing was used to evaluate the consumption of preparations served at a self-service lunch during 22 days. The lunch preparations (P) were weighing in scale Filizola ® with full capacity of 20 kg, before served, just like the leftovers unconsumed (L) and the rejection, after the distribution. The weight of the recipients containing the preparations was discounted from the total weight. The juices were measured in jars with full capacity of 1L, graduated in 100ml. the total consumption of meals (C) was obtained by the (C=P-L) formula and the per capita consumption, dividing the total consumption by the number of served meals.

The cooking factors of the preparations obtained by Amorim & Jokl (2004) and Amorim & Jokl (2006) were applied to obtain the total net weight of the respective ingredients. The information about the ingredients used on preparations were collected with the cafeteria cook. Based on the total net weight of the ingredients, the percentages of the ingredients were obtained. From the percentages the amount of each ingredient present in the respective preparation was calculated.

Then using the ratio of the ingredients and preparations and their respectively weights the amounts of macronutrients, fibers, calcium and iron were calculated based on data from Nepa/Unicamp (2006). The food reject index - relation between the remains returned on the plate by the student and the amount of preparations consumed - expressed as a percentage was used to correct the total energetic value of the meals (Gandra& Gambardella, 1983)

For macronutrients we used the average percentage in relation to the total energy needs (TEN) proposed by DRI (2004), as well as for the daily recommended intake for fibers, calcium and iron. The nutritional adequacy for consumed lunch by the preschoolers and the schoolchildren was based on the 35% percentage in relation to the average energy requirements stipulated for 1 to 3 years old children - 1300 kcal, 4 to 6 years old children – 1800 kcal, 7 to 9 years old – 2000 kcal and 10 to 12 years old – 2400 kcal (OMS,1998).

RESULTS

The results for the preparations weights, the leftovers unconsumed by the children and the total intake of meals and juices are presented in Table 1. The unconsumed leftovers in the distribution counter (5.79 ± 2.62kg) and the food reject (3.9 ± 1.2kg) obtained by nutritional diagnosis represent 23% and 16% related to the amount prepared (25 ± 3.2kg), respectively.

Table 1 – Average consumption of meals and juices

The average consumption of lunch preparations estimated by leftovers was 19.21 ± 3.18kg (Table 1) and the average per capita intake was 252.39 ± 47.28g and 58.76 ± 14.56ml juice (Table 2).

Table 2 – Per capita amounts of preparations consumed by students

Table 3 presents de average nutritional value for lunch, distributed in carbohydrates, proteins, lipids, energy, fiber, calcium and iron. The 16% percentage of reject was used to correct the nutrient contents. The average corrected energy value was 466 ± 113.84kcal and carbohydrates represented 48%, protein 24% and lipids 28% in relation to that total.

Table 3 – Average nutritional value of the evaluated lunch

Discussion

In the case of self-service food, system adopted by the cafeteria of a full time school, the students above 4 years old can choose the foods they desire to eat and also the amount they want. The 1 to 3 years old children are served by the educational agents.

The food preparations served, since consumed by students in the recommended portions, according to their nutritional needs, can provide the essential nutrients for regular development and growth of the child. Therefore when analyzing the meals menu offered to the students from this school, Santos et al. (2009) verified that it was served all food groups recommended for a healthy eating: fruits – 3 portions; vegetables – 4 portions, legumes – 1 portion, cereals, roots and tubers – 6.6 portions, meet and eggs, 3 portions, milk and dairy – 3/5 portions and sweets – 3/4 portions.

Based on the premise that serving adequate menus does not guarantee the adequate intake of nutrients of all students, we selected to evaluate the average lunch consumption of the students obtained by direct weighing of the prepared meals, leftovers not consumed and reject.

In spite of the great demand of time in the data collection, since the cafeteria did not have datasheets of the preparations, we selected this method. By transforming the weight of the preparation into raw ingredients, from the cooking factors and the percentage of the ingredients, the amount of ingredients used in the recipes of the preparations was obtained. These data can be used to plan the ingredients to be prepared to avoid unconsumed leftovers.

The leftovers and rejects values, 23% and 16%, are considered high when compared to the 10% goal proposed by Gandra & Gambardella (1983) and Mezomo (1994) such as leftovers as reject.

Lower values than the ones presented in this study were obtained by Amorim, Junqueira & Jokl (2005) in a nutritional adequacy study carried out in a self-service restaurant – 17% leftovers and 6.6% reject, showing the existence of leftovers in this kind of distribution.

To reduce the high per capita reject amount (52.27 ± 15.28g), regarding to the food served and unconsumed leftovers, it is suggested that the educators should make the students aware of to the importance of a balanced use of the resources available in nature, as a content to be discussed in the transversal subjects of the environment and health education proposed in the national curricular parameters (Brasil, 1999). This way the student acts himself on the task of built meanings about the learning contents in situations experienced in school daily life.

The daily average intake of 252.39g meal and 58.76ml juice, equivalent to 466 ± 113.84kcal, reaches the energetic needs only for 1 to 3 years old preschoolers (36%). This group of children represents the minority of students (13%), while the majority of children are in the 7 to 10 years old range (32%), followed by 4 to 6 years old children (30%), 11 to 12 (25%). For 4 to 6 years old children (32%), 7 to 10 (26%) and 11 to 12 (19%) the consumption was lower than 35%.

Children with 4 to 12 years old can eat by themselves and ingest a lower amount of meal, because they are not totally supervised by educational agents and nutritionists, just like happens with 1 to 3 years old children. The low intake of food can be explained by the fact that the collation and the lunch are served in nearly hours, and this can inhibit student’s appetite.

Santos et al (2009) evaluated the nutritional status of these children and found 10% overweight and 5% obesity among them. Thus, it would be of great importance to analyze the intake of other meals and the food consumed at home.

Several studies have shown that in addition to energy deficiency, there is low iron and calcium intake in preschoolers (Castro et al. 2005: Magalhães, Ramalho & Colli, 2001; Salay & Carvalho, 1995). Comparing the intake of iron from preschoolers (1.92 mg ± 0.83 mg) with the amount recommended for a meal (2.45 mg to 3.5 mg) it was found that the value was low. Were used 35% of Recommended Dietary Allowance for iron for children from 1 to 3 years and 4 to 8 years old, and this values included other age’s groups (DRI, 2004). For calcium the intake was 27.75 g ± 10.41g and the nutritional adequacy will depends from this nutrient consume in others meals, in which milk and dairy are expected to be included. The fiber intake was 4.41 g ± 1.38g, considered low, because the children still have to consume 16g in others meals in order to meet the recommendations for a healthy eating. Fiber intake of 4.41 g ± 1.38 g was considered low, since children will still have to consume 2.3 g to 6.5 g fiber at other meals. Adequate Intake fibers were considered 35% for children aged 1 to 3-4 to 8 years and 9-13 years of age (DRI, 2004).

When analyzing data for food preparations, it was verified that the average daily intake of rice was 66.56 ± 12.61g, a value that is similar to the recommended rice portion for 2 to 3 years old children – 62g (Philippi, Cruz & Colucci, 2003). With regard to beans the average daily consumption was 36.83 ± 6.36g, a higher value than the amount proposed by 2 to 3 years old children according to Philippi, Cruz & Colucci, (2003) – 26g. For children over 4 years of age it is suggested to apply the values described by Philippi et al. (1999) for diets of 1600 to 2200 kcal in which a portion of rice and beans equals 125 and 86g, respectively.

The consumption of fixed preparations, rice (CV=18.94%), beans (CV=17.26%) and juice (CV=25.95%) did not showed large intake variation. However the main course (81.53 ± 33.56g), garnish (34.02 ± 16.11g) and salads (33.51 ± 11.31g) showed larger intake variations, confirmed by the coefficients of variation of 41.15%, 47%, 35% and 33.75%, respectively and also due to the large variety of food preparations served.

To engage the students in the adequate consumption of meals, it is suggested to classify, in the classroom activities, the foods served in the respective food groups and to show the portions in home measures. Learning how to adequate portioning of the meals might consequently promote students’ healthy eating practices in the school environment and at home. Knowledge about nutrients and their functions in the body, nutritional needs described in portions according to sex, age and activity can be explored in the natural sciences discipline according to the proposal of the national curricular parameters using non-directive teaching strategies (Brasil, 1997).

Conclusion

The evaluated menus served on a self-service full time school do not seem to assure the adequate intake of nutrients necessary to student’s health. However, the variety of foods served provides the possibility of nutritional adequacy of the meals consumed by students, if health education is part of school curricula as a transdisciplinary theme in a contextualized and systematic way, taking into account all aspects involved in the development of students' habits and attitudes related to food.

References

I. Amorim, M. M. A. & Jookl, L. (2004) Fatores de cocção de alguns pratos protéicos. [Cooking Factors of some protein dishes] In: XIX Congresso Brasileiro de Ciência e Tecnologia de Alimentos, Recife. Congresso Brasileiro de Ciência e Tecnologia de Alimentos. Recife: Sociedade Brasileira de Ciência de Tecnologia de Alimentos, 2004.

II. Amorim, M. M. A. & Jokl, L. (2006) Fatores de cocção das preparações pela pesagem direta. [Cooking Factors of preparations by direct weighing] In: 14º Congreso Latinoamericano de Nutrición, Florianópolis. Congreso Latinoamericano de Nutrición. Florianópolis: Sociedade Latinoamericana de Nutrición, 2006.

III. Amorim, M. M. A.; Junqueira, R. G., Jokl, L. (2005) Adequação nutricional do almoço self service de uma empresa de Santa Luzia – MG. [Nutritional Adequacy of a self-service lunch in a Santa Luzia /MG company] Rev. Nutr., 18 ( 1), 145-156.

IV. Brasil (1997) Secretaria de Educação Fundamental. Parâmetros Curriculares Nacionais: primeiro e segundo ciclos. [National Curricular Parameters: first and second cycles] Brasília: MEC/SEF.

Brasil (1999) Secretaria de Educação Fundamental. Parâmetros Curriculares Nacionais: temas transversais. [National Curricular Parameters: cross-cutting themes] Brasília: MEC/SEF.

V. Castro, T. G., Novaes, J. F., Silva, M. R., Neuza, B. C., Sylvia, C. C. F., Adelson, L. A. T. & Paulo, F. G. L. (2005). Caracterização do consumo alimentar, ambiente socioeconômico e estado nutricional de pré-escolares de creches municipais. [Characterization of food consumption, socioeconomic environment and nutritional status of municipal day cares preschoolers] Rev. Nutr., 18 (.3), 321-33.

VI. Danelon, M. A. S.; Danelon, M. S. & Silva, M. V. (2006) Serviços de alimentação destinados ao público escolar: análise da convivência do Programa de Alimentação Escolar e das cantinas. [Food services for school public: coexistence analysis of School Food Program and cafeterias] Segurança Alimentar e Nutricional. 13 (1), 85-94.

VII. Dietary Reference Intakes (DRI). (2004) Applications in dietary assessment. Food and Nutrition Board. Instistute of Medicine. National Academy Press: Washington, D.C.

VIII. Gandra, Y. R. & Gambardella, A. M. D. (1983) Avaliação dos serviços de nutrição e alimentação. [Food and Nutrition Services Avaluation] São Paulo: Sarvier, 113 p.

IX. Magalhães, P.; Ramalho, R. A. & Colli, C. (2001) Deficiência de ferro e vitamina: avaliação nutricional de pré-escolares de Viçosa (MG/Brasil). [Iron and Vitamin deficiency: Nutritional evaluation of Viçosa (MG/Brazil) preschoolers] J. Brazilian Soc. Food Nutr., 21, 41-46.

X. Mezomo, I. F. B. (1994) A administração de serviços de alimentação. [Food Services administration] 4. ed. São Paulo: Metha.

XI. Nepa/Unicamp. (2006) Tabela Brasileira de Composição de Alimentos – versão II. [Brazilian Food Composition Table – II version] Campinas: Nepa-Unicamp, 2006.

XII. OMS (Organização Mundial de Saúde). (1998) Necessidades de energia e proteína. [Protein and energy Needs] São Paulo: Roca. 225 p. (Série de relatos técnicos 724. Junta do conselho de especialistas da FAO/ WHO/ ONU 1985).

XIII. Philippi, S.T.; Latterza, A.R.; Cruz, A.T.R. & Ribeiro, L.C. (1999) Pirâmide alimentar adaptada: guia para escolha de alimentos. [Adapted food pyramid: Guideline for food choices] Rev Nutr. 12 (1), 65-80.

XIV. Philippi, S. T.; Cruz, A. T. R.; Colucci, A. C. A. (2003) Pirâmide alimentar para crianças de 2 a 3 anos. [Food pyramid for 2 to 3 years old children] Rev. Nutr., 16 (1), 5-19.

XV. Salay, E.; Carvalho, J. F. (1995) Avaliação do programa de merenda escolar do município de Campinas, Brasil. [Evaluation of School lunch program of Campinas, Brazil] Arch. Latinoam. Nutr., 45 (34), 167-171.

XVI. Santos, R. G.; Liboni, J. A.; Carvalho, S. S.; Oliveira, M. A. C.; Coelho, P. C.& Amorim M. M. A. (2009) Adequação das porções das preparações servidas em uma escola particular de Belo Horizonte. [Adequacy of preparations portions served in a private school in Belo Horizonte.] In: XVI Encontro Nacional e II Congresso Latino-americano de Analistas de Alimentos, Belo Horizonte. Enaal 2009.

XVII. Vitolo, R. M. (2008) Nutrição da gestação ao envelhecimento. [Nutrition from gestation to aging] 1. ed. Rio de Janeiro: Rubio.

Nutritional Adequacy of the Lunch Consumed by Children in a Private School in the Metropolitan Region of Belo Horizonte/Brazil

Maria Marta Amâncio Amorim

Nutritionist. PhD in Nursing. Nutrition and Gastronomy of University Center UNA. Center for Studies and Intercultural Relations of the Open University of Lisbon

Ariane Cristina Leite, Ingrid Martins dos Santos, Luci Aparecida Conceição

Nutritionist Graduate from Center UNA, Brazil

Alessandra Hugo de Souza

Nutritionist Graduated from the University Center of Belo Horizonte, Brazil

Adriana Keller Coelho

Nutritionist. Master in Health Sciences. Professor at the Pontifical Catholic University of Minas Gerais, Brazil

Abstract:

Objective: Considering the importance of assessing nutritional deficiencies in childhood, the present study aims to evaluate the adequacy of nutrients consumed at lunch by preschoolers of a private school in the Metropolitan Region of Belo Horizonte / MG. Methods: Direct food weighing was used to access the lunch consumed by 28 children aged 2 to 5 years old on four consecutive days. The nutritional adequacy of the lunch was analyzed through the agreement with the National School Feeding Program guidelines. Results: The menu did not meet 20% of the nutritional needs in relation to the energy supply, proportions of carbohydrate, fiber and sodium, as well as iron. Protein, vitamin A and zinc exceeded the recommendation for both age groups. Lipid levels were higher than recommended for children aged 2 and 3 years and remained below the recommendations for those aged 4 and 5 years. Conclusion: There is need for a reformulation of the school menu, by adjusting the nutrient and energy content to the children’s nutritional requirements. The introduction of new foods should be planned to improve children’s acceptance for healthy foods and to promote healthy eating habits.

Keywords: Preschooleducation. Food consumption. Nutritional adequacy. School lunch

Introduction

In childhood, food should be adequate in quantity and quality in order to ensure the essential nutritional needs necessary for optimal development and growth, in addition to building healthy eating habits. Inadequate habits can cause nutritional deficiencies, affecting child growth and development, contributing to obesity and accelerating chronic non-communicable diseases (NCDs) in adulthood. Therefore, healthy food should be offered to children at both home and school (Inoue, Osório, Taconeli, Schmidt & Almeida, 2015). To promote healthy eating habits from childhood, it is important to evaluate the adequacy of nutrient intake by preschool children in order to identify the aspects that can be corrected at this stage.

In Brazil and in the world, it is still common the lack of energy and other nutrients in the children’s diet. As a result, over 195 million children all over the world are chronically malnourished from eating a reduced amount of food that does not fully address their basic energy and nutritional needs (Neitzke, Molina & Salaroli, 2012).

Current studies have revealed that deficiencies in micronutrients such as zinc, vitamin A, and iron are risk factors associated with growth deficit in children. It is believed that the deficiencies of iron and vitamin A hamper the growth only in severe deficiency situations and mild zinc deficiency can cause growth damage. Nutrition plays a key role in physical growth, neuropsychological development and in combating infectious diseases, especially children (Pedraza & Queiroz, 2011).

Another important nutrient in children’s diet is sodium, a primal micronutrient to keep osmotic pressure, because it acts in the transportation of nerve impulses and muscular contraction. However, an excessive ingestion of sodium is associated with high blood pressure, thus limiting its consumption on childhood can lower the risk of this disease in adulthood (Boscari & Pereira, 2015). Considering the importance of assessing nutritional deficiencies in childhood, the present study aims to evaluate the adequacy of nutrients consumed at lunch by preschoolers of a private school in the Metropolitan Region of Belo Horizonte / MG.

Methods

The present study was carried out in a private school Food and Nutrition Unit (FNU), located in the metropolitan region of Belo Horizonte/MG. The school offers children’s education to 28 children aged between 2 and 5 years, mostly 2 years old children (82%) and 18% of 5 years old children. Boys were in the major number (57%) and 33% girls.

The data collection was performed in 2016 August by direct weighing of lunch preparations (Amorim, Junqueira & Jokl, 2005). The preparations and unused leftovers were weighed in a digital scale graduated at 1g with a total capacity of 10kg. The recipients used for packing the preparations were weighed and discounted from the total weight. The weights of the total preparations (T) were deducted from their respective leftovers (L) to obtain the consumptions (C) of the preparations. The per capita consumptions of the preparations were determined by the division of the total consumptions by the number of children served in the day. The percentage of leftovers in relation to the quantities prepared was also calculated. Based on the ingredients described in per capita consumption, energy, carbohydrate, protein, lipid, fiber, sodium, zinc, vitamin A and iron contents were calculated using the Brazilian Food Composition Table (Taco, 2011). The recommendations from the National School Feeding Program were used as reference for nutritional intake adequacy analysis (PNAE, Brazil, 2013), which, for lunch, corresponds to 20% of the students energy needs. For 1 to 3 years old children it is stipulated 200 kcal of energy value, 3.5g carbohydrates, 6.3g proteins, 5.0g lipids, 3.8g fibers, 60ug vitamin A, 1.4mg iron, and 0.6mg zinc. For 4 to 5 years old children the lunch energy value is 210kcal, 43.9g carbohydrates, 8.4g proteins, 6.8g lipids, 5.0g fibers, 80ug vitamin A, 2.0mg iron, 1.0mg zinc (Brazil, 2013).

Results

Table 1 shows the institutional lunch menu, which was the selected meal for analysis.

Table 1. Metropolitan Region of Belo Horizonte/MG private’s school daily menu in 2016.

In table 2, quantitative data for the weight of prepared, consumed and leftover foods are presented.

Table 2. Weight of prepared, consumed and leftover foods in lunches of a private school at the Metropolitan Region of Belo Horizonte/MG, 2016.

In table 3 the quantities per capita for the analyzed preparations menu for four consecutive days are described.

Table 3. Quantities per capita of lunch preparations of a private school in the Metropolitan Region of Belo Horizonte/MG, 2016.

The amounts of macronutrients, fibers, energy, micronutrients and percentage of adequacy consumed at lunch from Monday to Thursday are expressed at table 4.

Table 4. Amounts of macronutrients, fibers, energy, micronutrients and percentage of adequacy consumed at lunch at the private school in Metropolitan Region of Belo Horizonte/MG, 2016

Discussion

At the studied school, children remain from 07:30h to 17:00h and are offered 4 meals: collation, lunch, afternoon snack and dinner. The collation consists of a fruit; lunch includes a main course (beef or chicken), a garnish, rice, beaten beans and a vegetable salad. For the afternoon snack it is served natural juices, teas, jelly, yogurt or chocolate milk, and cookies, cakes or breads. At dinner children are offered some kinds of broth, such as beans broth, and it is also offered: soups, composed rice and others.

When observing the institution lunch menu, the meal chosen for analysis (Table 1), and one can conclude that this menu is very varied, allowing a healthy diet. Children need to be stimulated to eat, and for that happen the elaborated menu should be attractive, colorful and creative. The school has an important role in offering a healthy diet and should encourage the child to try different kinds of foods. In addition, based on motivational classrooms activities regarding nutrition education, school should contribute significantly to positive changes in eating practices (Oliveira & Mendes, 2008). At preschool period, the child is more vulnerable to some infections, and needs an adequate energy supply (Bortolini, Gubert & Santos, 2012). The average percentage of leftovers (36.18%) found at this study (Table 2) was very high, trespassing the acceptable average, 3%. In the Amorim & Gatti study (2010), the high percentage of lunch leftovers can be explained by the fact that the meals are intentionally produced in a higher amount than need for a meal, in order to be offered at dinner, due to the scare number of professionals to prepare them. In the studied institution the lunch leftovers were reutilized according to the dinner menu and the exception were the salads that were discarded. On Wednesday there was less leftover, because the garnish was baked potato, which is usually a well-accepted food in all ages, and thus higher consumption of rice in his day (Table 2). According to Pikelaizen & Spinelli (2013), the leftovers may reveal planning errors, which can be incompatible with this kind of public.

The per capita consumptions average was similar to the Pikelaizen & Spinelli (2013) study, carried out in a private school in São Paulo/SP with children age 1 to 10 years old, which showed a 207.9g average per capita consumption (Table 3). The most consumed food among children aged 2 to 5 years old was rice, followed by beans, main course, garnish and salad. The per capita amount of rice varied from 50.81g to 76.45g, which indicate higher values than the ones found by Pioltine & Spinelli (2012) of 29g to 36g in 2 to 10 years old children in São Paulo/SP. The average per capita amount of the referred food (67.36g) was higher (55g) than in Faquim, Oliveira & Spinelli (2012) study with 5 to 6 year old children in a São Paulo school, as well as in the study by Vieira, Silva, Navarro, Mendonça, Spinelli & Matias (2015) involving 2 to 6 years old children attending a private school in São Paulo, which was 50.6g.

For beans, the per capita amount ranged between 59.69g to 67.25g, which indicate higher values than those found by Pioltine & Spinelli (2012), of 21 to 37g for beans, consumed by children at the same age. The average per capita consumption value for beans was 62.77g, a higher value than the average offer per capita found in the study by Vieira et al. (2015) and lower than the one observed by Faquim, Oliveira & Spinelli (2012), that was 80g.

Wednesday was the day when children ate less as main course, 24.55g, a value similar than Faquim, Oliveira & Spinelli (2012) study, in which the per capita quantity was 20g, lower values than the average value found (43.51g).

The garnish average consumption was 20.96g, varying from 6.5g to 41.26g; with the day pasta was served being the one revealing the higher amount of leftover. This may have been due to the fact that pasta was prepared without sauce and the children show better acceptance for stew. In a study by Faquim, Oliveira & Spinelli (2012), with 5 to 6 years old children, it was found 20g of garnish intake, a mean value similar to the one observed in the present study.

Salad, among all the preparations, was the most rejected food by children, particularly when it included lettuce and tomato. Similarly, in the study by Pegolo & Silva (2010), there was a low consumption of vegetables by schoolchildren in a city of São Paulo, indicating a possible deficiency in fiber consumption and the need to highlight the importance of these foods, which are good sources of this nutrient. Thursday was the only day that there wasn’t salad leftover, because in that day the menu served was: meet stew with yam, braised peas, simple rice, beaten beans and broccoli. It has generally been found that the preparation of the salads was not adequate, showing little attention to important organoleptic aspects, which are known to have impact on appetite and intake. In addition to these sensorial aspects that can limit the stimulation and interest on eating salads, it is possible that the low acceptance observed in most children regarding this food was due to the lack of encouragement by adults. Although a nutritionist defines the menu, there are some improvements to be done such as change the texture and consistency of beans, which are served always beaten, because it is necessary to stimulate children’s chewing.

According with Goes et al. (2012), to ensure an adequate intake of carbohydrates, proteins and lipids among preschool children is of great importance, because the deficiency of these macronutrients in childhood can permanently affect their height, in addition to impairing their physical and intellectual development. Regarding carbohydrates, Pioltine & Spinelli (2012) found in their study, performed with 2 to 10 years old children from a private school in a city of São Paulo, an intake of 30.37g was found, indicating a higher value than the average value found in the present study (Table 4). The carbohydrate content provided by the menu was below the recommendation, reaching only half for 2 to 3 years old preschoolers and one third for 4 to 5 years old. In a similar way, at Alencar et al. (2016) study, carried out in nurseries in the Northeast, the carbohydrate intake evaluated in one day was also below the PNAE recommendations: 69% for children aged 1 to 3 years old and 51% regarding 4 and 5 year old children.

Protein was above the recommendations (Table 4), being 1.7 times higher for 2 to 3 years old children and 1.3 times higher for 4 to 5 years old. These observations are in line with those of Alencar et al. (2016) study carried out in Northeast nurseries with 1 to 5 years old children, in which protein also exceed the recommendations: 188.6% in 1 to 3 years old range and 141.3% for 4 to 5 years old children. Similar values to those found in this present study were observed by Tércio, Tolentino, Lopes & Pinho (2013) in a research involving children aged 2-12 years from a public school in Espinosa/MG, in which protein has reached 10.89g. Pioltine & Spinelli (2012) found 8.56g, a lower value than the one observed in the present study for this macronutrient, just like the value found (9.4g) in the study by Dias, Cintra, Souza & Aranha (2012) performed in Botucatu/SP with children of similar age range. Schimiloski & Cezar (2014) found a protein value of 10.1g in basic education children’s lunch in Cascavel/P.

The average lipid estimated intake (Table 4) at lunch was lower (5.8g) than the one found by Dias et al. (2012), which was 15.38g. Lipids were above the average for 2 to 3 years old children and below the average for 4 to 5 years old. Based on these findings, we suggest the addition of olive oil as salad dressing to be offered to 4 to 5 years old children.

The energy provided in the four days of assessment did not reach the PNAE recommendations in the two age ranges considered in the present study (Table 4). The same happens in Alcantara, Martins & Dorna (2008) study carried out in Seropédica/RJ, in which the results for energy provided by lunch ranged between 142.8 to 268kcal in 0 to 4 years old children. Pioltine & Spinelli (2012) found a value of 233.53kcal in 2 to 10 years old preschoolers’ lunch, which is not in line with the recommendations for the entire age spectrum.

In contrast with the present study, Alencar et al. (2016) found values of energy above the PNAE recommendations for 2 to 3 years old children (126.4% of adequacy) while in 4 to 5 years old children, it was observed 93% of adequacy in the first day care center evaluated. On the second day care center, 78% of the energy needs were reached for 2 to 3 years old children and 57.9% for 4 to 5 years old, which was similar to the results obtained in the present study.

As regards dietary fiber, the average results provided by the menu did not reach the recommendations (Table 4), such as observed by Tércio et al. (2013). The values were similar to Dias et al. (2102) and Tércio et al. (2013) studies, in which 3.66g and 3.75g of fibers were found, respectively, at 2 to 5 years old preschoolers’ lunches. The fourth day was the only day in which fiber content provided by the menu was within the recommendations, 102% for 2 to 3 years old children. For 4 to 5 years old children the fiber content did not reach the recommendations in any of the days evaluated. In a study conducted in Belo Horizonte/MG, Almeida, Fontes, Anjos, Santos & Pereira (2015) found 23.7% and 13.7% of fiber adequacy in children aged 1 to 3 years and 4 to 5 years, respectively. One possible cause for the low fiber intake observed in children is the low acceptance for vegetables in salad provided by the menu.

The sodium content showed a great variation in the last of the evaluated days and the average consumption was below the necessary. The average amount of salt used in the preparation of food was 1.2g. Since sodium is an important electrolyte for the body, controlling the blood volume, transmitting impulses and in out of substances that remains in cells (Dias et al. 2012), it is important to evaluate if its intake is adequate in other meals. In a study carried out in public day care centers in São Paulo/SP by Silva et al. (2014) the average sodium consumption was 413.4mg, a value higher than the recommendation and in also the one observed in this study. Similar results were obtained in Tavares et al. (2012) study, in which a high sodium intake was observed in more than 70% of children aged 0 to 5 years attending a public day care center in Manaus/AM. A study involving 2 to 5 years old preschoolers, has shown that this micronutrient intake above nutritional recommendations was associated to high blood pressure in childhood, exposing this children to risk of development of early and future systemic arterial hypertension (Vitolo, Louzada, Rauber & Campagnolo, 2013).

Zinc was above recommendations (Table 4), reaching 316% for 2 to 3 years old children and 190% for 4 to 5 years old. In Zanella, Zemolim, Zanardo & Spinelli (2015) study in an Erechim/ES philanthropic entity, the average zinc content for preschoolers, only reach 46.8% of recommendations. Also in Queiroz (2015) study with 4 to 6 years old children in a city of Assú/RN, it was found 213% adequacy, which was a higher value than the one of this study.

Vitamin A exceeded the recommendation for both age ranges (Table 4). However, this was due to the particularly high amount of vitamin A in a food offered during the week, the liver. In a study performed by Alencar et al. (2016) in Brazil’s Northeast, the vitamin A content was also in high percentage: 459.5% and 344.6% for children aged 1 to 3 years and 4 to 5 years, respectively. This was due to the presence of foods such as papaya, watermelon, carrots, pumpkin, among others, during the week. Queiroz (2015) found 151% adequacy for vitamin A in study carried out in the city of Assú/RN with 4 to 6 years old children.

Iron was above the recommendations for both 2 to 3 years old and 4 to 5 years old children (Table 4) which can be explained by the low ingestion of meet. In general, Queiroz (2015) in his study with 4 to 6 years old children from the city of Assú/RN found that iron was 71% below the recommendations.

According to Pioltine &Spinelli (2012) it is necessary to encourage that iron was because iron and zinc deficiency are related to the low ingestion of this food. However, it is important to note that contrasting results have been published, revealing adequacy percentages of iron of 191,4% in 1 to 3 years old children and of 134% in children aged 4 to 5 years (Alencar et al., 2016).

Conclusion

Globally, the menus analyzed in the present study were outside the standards recommended by PNAE for most of the nutrients. Therefore, changes are necessary, such as increasing the amount of energy and carbohydrates, since these parameters were below the values recommended by PNAE and decreasing the amount of protein that was above the recommended one. It is necessary increase the amount of fibers stimulating the consumption of grains, fruits and vegetables and foods riches in non-heme iron. Vitamin A, as well as the mineral zinc, shown to be above the recommendations, a fact that can be explained by the presence of liver which is particularly rich in these nutrients. The introduction of new foods on the menu is of great importance not only to improve children’s acceptance for healthy foods and therefore to promote healthy eating habits, but to adjust the food provided to the nutritional requirements during growth.​
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Nutritional Composition Evaluation of a Public School Lunch from Contagem/Brazil

Maria Marta Amancio Amorim

Nutritionist. PhD in Nursing. Research CEMRI/Lisboa. Professor In University Center UNA, Brazil

Ester Alves Loubach, Rafaela Martins Pereira, Ana Clara Abreu Soares, Kamila Costa Silva, Lílian Gomes Machado, Maíra Baêta Sousa, Maria Conceição de Souza, Rafaela Fernanda Resende da Silva

Academic Nutrition Course in University Center UNA , Brazil

Alessandra Hugo de Souza

Nutritionist. Geriatric Nutrition Specialist

Eric Liberato Gregório

Nutritionist. Master in Fisiology. Professor in University Center UNA, Brazil

Abstract

The students of basic education, child education, fundamental education, secondary education and education of young people and adults enrolled in public schools are attended in Brazil by the National Program of School Feeding (PNAE). School meals are offered freely in public schools by PNAE financial overpayment. The present study aimed to evaluate the menu of a school of the state education network in the Municipality of Contagem / Brazil, as opposed to the recommendations of the PNAE for schoolchildren aged 11-15 and 16-18 years. This study was carried out at a school in the state network of the municipality of Contagem, Brazil, during the first half of 2016. An evaluation of the biweekly menu offered was realized. Based on ingredients and per capita amounts informs by school, was calculated the amounts of energy, macronutrients, fibers, and the micronutrients: Vitamin C, Vitamin A, Calcium, Iron, Magnesium and Zinc, using the Brazilian Food Composition Table. The values obtained were compared to the reference values for schoolchildren, settled down by PNAE in order to supply 20% minimum of diary necessities for a meal. The menu analyzed was inadequate in relation to most PNAE recommendations for students aged 16-18 years and did not meet the recommendations for energy, carbohydrate, vitamin A, magnesium, calcium and iron for students aged 11-15 years. It is evident that there is a need to differentiate the per capita quantities offered to the students of the older age group, in order to reduce nutritional risk, as well as to better meet the recommendations of the PNAE.

Keywords: School Meals, Teenagers, Preschoolers

INTRODUCTION

The students of child education, basic education, secondary education and education for young people and adults of public state network schools are attended by the National Program of School Feeding (PNAE). The school meals are offered for the public schools by the PNAE financial overpayment. This is a Brazilian Federal Government project that had is start in 1955, with the intention of contributed for students growth, development, learning and academic performance, by promoting health eating habits for students that make public education (PNAE, 2012). Children and teenagers had the right of a health meals, that can be provide at the school or at home. Since 1994, PNAE acts in a decentralized way, according to Law 8.913/94, that establishes the guidelines for this process. The expectation is improve the provision of meals, attend the students eating habits, encourage the local and regional economy, decrease costs and stimulate the community participation (Muniz & Carvalho, 2007). The union of the states and municipalities transfers, per school day, for each student, according to their position in education, the following values: day care: R$1.07, to preschool: R$0.53, to indigenous and quilombolas schools: R$0.64, to elementary, middle and youth education and adult education: R$0.32, to integral education: R$1.07, to students of the More Education Program: R$1.07, to students attending the Specialized Educational Attendance in the counter shift: R$0.53 (PNAE, 2017). The school plays an important role in providing a healthy diet and must encourage the child to experiment different types of food, working on educational forms that lead to changes in eating habits (Oliveira & Mendes, 2008).Therefore, the purpose of this study was evaluating the lunch menu of a public state network of Contagem/Brazil against the recommendations of National Program of School Feeding.

MATERIALS AND METHODS

Was realized the biweekly evaluation of a lunch menu of a public state school of Contagem/ Brazil, for 11 to 15 years old students and 16 to 18 years old students in 2016 March. A visit was made at the school, where it was obtained de biweekly menu, the ingredients per capita amounts and the served portions.Based on the ingredients used in lunch preparations the energy, macronutrients, fibers, vitamin C, vitamin A, calcium, iron, magnesium and zinc values were calculated, using the data from Food Composition Tables (Taco, 2006; Philippi, 2002). Was used the PNAE recommendation for lunch, which correspond to 20% of students energy necessity. For 11 to 15 years old students is stipulated the lunch energetic value of 435 kcal, carbohydrates 70.7g, proteins 13.6g, lipids 10.9g, fibers 6.1g, vitamin A 140ug, vitamin C 12mg, calcium 260mg, magnesium 63mg, iron 2,1mg and zinc 1.8mg. for 16-18 years old students the lunch energetic value is 500kcal, carbohydrates 81.3g, proteins 15.6g, lipids 12.5g, fibers 6.4g, vitamin A 160ug, vitamin C 14mg, calcium 260mg, magnesium 77mg, iron 2.6mg and zinc 2.0mg (PNAE, 2012). Statistical analyzes performed between the groups of children and adolescents in the age group of 11-15 years and adolescents in the age group of 16-18 years were performed in GraphPad Prism® version 3.0 after performing the normality test through analysis of variance - Anova One Way, for parametric and non-paired data, followed by Newman Keuls post-test. We adopted p≤0.05 as reference values of statistical significance, and data were expressed as mean ± standard deviation.

RESULTS

According to the responsible director, the study school had 545 students enrolled in high school, in 2016, and 322 of the students were female (59%) and 223 were male (41%).

Table 1. Energetic value, macronutrients, fibers, minerals e vitamins of the biweekly menu of a state public school of Contagem/Brazil.

* 1-Rice, meat and banana; 2-Seasoned rice; 3-Colorful Rice with ground beef; 4- Rice and beans; 5-Greek rice; 6-Rice with light Brazilian bean stew; 7-Baião de três; 8-Scrambled food; 9-Canjica with coconut; 10-Canjica with grated coconut; 11-Canjiquinha; 12-Beans soup; 13-Vegetables and pasta soup; 14-Farofa with meat, eggs and kale; 15- Pasta with Bolognese sauce.

Energetic value

The average amount found (330.77±190.20) was below the PNAE recommendation, reaching 76.04% of adequacy for 11-15 years old (450 kcal) and 66.15% for 16-18 years old (500 kcal), and no statistical difference was observed (p˃0.05), being presented in Figure 1. The macronutrients contribution to the average energetic value found at the menu was 50.52% for carbohydrates (167.12 kcal), 16.20% for proteins (53.56 kcal) and 31.57% for lipids (104.40 kcal).

Figure 1. Adequacy of energy average offered by the lunch menu for 11-15 and the 16-18 years old

Macronutrients

The adequacy of macronutrients from the menu lunch for the age group of 11-15 and 16-18 years is shown in Figure 2. The mean of the carbohydrate values (41.78 ± 23.02) of the menu for students of 11 at 15 years reached 59.09% of the minimum recommended by PNAE (70.7 g), compared to 20% of daily nutritional requirements. With the same criterion for the age group of 16 to 18 years, it reached 51.39% (41.78 ± 23.02) of the minimum recommended by the PNAE (81.3 g).

The proteins average values for 11-15 years old students reached 98.46% (13.39±11.64) of the minimum recommended by PNAE (13.6g) and for 16-18 years old reached 85.83% (13.39±11.64) adequacy related to recommendation (15.6g).

Related to lipids, the average amount (11.60±12.73) exceeded the recommendation (10.9g) for 11-15 years old students with 106.42% adequacy e for 16-18 years old the results (11.60±12.73) reached 92.8% of the minimum recommended (12.5g).

Figure 2. Adequacy of macronutrients for the lunch menu to 11-15 and 16-18 years old students.

*Significative diference – p≤0.05

The 11-15 years old students exceeded in 7.38% (6.55±5.372) for the recommended value for fibers (6.1g) and the 16-18 years old students exceeded in 2.34% (6.55±5.372) above the recommendation (6.4g). However, wasn´t observed statistical differences (p˃0.05) for both age ranges. This data are illustrated at Figure 3.

Figure 3. Adequacy for lunch menu fibers for 11-15 and 16-18 age ranges

Micronutrients

The micronutrients adequacy offered by the lunch menu for 11-15 and 16-18 age ranges is illustrate in Figure 4.

Related to Vitamin A, it was verified that the amount offered by the menu (104.27±72.44) did not reach the recommendation for 11-15 years old (140ug), presenting a result of 74.48% of adequacy. Also didn´t reached the recommendation for 16-18 years old (160ug), which was found 65.17% (104.27±63.39) adequacy. The same occurred for vitamin C, presenting 91.58% (10.99±168.0) of adequacy for age group of 11-15 years old (12mg) and 78.5% (10.99±144.0) for 16-18 years old (14mg). It was observed that magnesium also was below recommended, reaching 60.49% (38.11±46.26) of adequacy for 11-15 years old (63mg) and 49.49% (38.11±37.85) for 16-18 years old compared to PNAE recommendation (77mg).

In contrast, related to zinc, the menu exceeded by far the recommended for both age groups. Was found the adequacy of 325.56% (5.86±715.0) for 11-15 years old (1.8mg) and 293% (5.86±643.5) for 16-18 years old students (2mg).

For calcium was verified that the offered amount by the menu was insufficient for both age ranges, and was found in both ranges only 28.37% (73.76±33.78) adequacy, according to the PNAE recommendation (260mg).

Related to iron was verified that the amount offered by the menu for 11-15 years old, obtained 86.19% (1.81±68.39) of adequacy compared to the PNAE recommendation (2.1mg). For 16-18 years old iron showed 36.19% (1.81±55.24 )of adequacy related to PNAE recommendation (2.6mg).

Figure 4. Adequacy of micronutrients offered by the lunch menu for 11-15 and 16-18 age ranges

Discussion

By observing the preparations served, describes in footnote on the table 1, verified that the menu is very diversified e follows, in part, the PNAE recommendations. The menu offered, three times a week, salty meals with foods rich in iron, like rice with meat and banana, and Colorful rice with grounded meat, as PNAE recommendations. The menu offered foods rich in calcium, in on various days of the week, like Canjica with coconut, Farofa with meat, eggs and kale. However the menu showed inadequate for the supply of fruits, because for the PNAE recommendations, the menus must offered at least, three fruits portions for week.

Energetic value

It is important to increase the energetic values of the portions, since the deficient intake of energy and some micronutrients, especially vitamins and a few minerals may harm the development of linear growth during adolescence (Oliveira & Osório, 2005).

Regarding the energetic value analyzed in the menu, it was considered inadequate for both ages range, not supplying the energetic value recommended by PNAE. The meals must offer 20% (twenty percent) minimum of daily nutritional necessities in a offered meal for students enrolled in basic education, part time, 30% (thirty percent) minimum of daily nutritional necessities when offered two or more meals for students enrolled in basic education, except for par time daycares, 70% (seventh percent) minimum of nutritional needs , distribute at three meals minimum, for students enrolled at More Education Program and for those enrolled in full time schools (PNAE, 2012).

The general average of the energetic value found in the research was 330.77 kcal, remain 26% and 33% below the minimum recommended by PNAE for 11-15 years old (450 kcal) and 16-18 years old (500 kcal). Similar results were found by Silva & Fernandes (2014) in a study realized in Pernambuco, were none of the offered meals to the 11-18 years old students furnished the PNAE recommendations regarding energetic value. Similarly, Rossato & Storck (2016), in a study realized in educational institutions at state network of the western region of Santa Maria, was found an offer of 114 kcal at the analyzed menu, a lower value than those founds at the present study (330.77 kcal) which correspond to 27% of adequacy.

In the world there is still a lack of energy and other nutrients in the feeding of children. As a result, more than 195 million children in various parts of the world are chronically malnourished from eating a reduced amount of food that does not meet their basic energy and nutritional needs (Neitzke, Molina & Salaroli, 2012).

Macronutrients

In a balance diet, the carbohydrates should represent the must account of energetic intake. This macronutrient is universally the most accessible source, and its excessive consumption harmful to the health, since occurs the conversion of absorbed glucose in glycogen, which considerably increases body weight (Philippi, 2015).

The analyzed menu offered insufficient amounts of carbohydrates for both researched ages range, showing 59.09% of adequacy for 11-15 years old (70.7g) and 51.39% of adequacy for 16-18 years old students (81.3g) against the PNAE recommendations.

Similar values were found in a study carried out by Silva & Gregório (2012), where the average amount of carbohydrates reached only 83% of that recommended by the PNAE, for students aged 11-15 years, higher than that found in the present study (59.09%), however, both results do not reach the recommended level for the age group. According to these authors carbohydrates represent the most important source of energy coming from the diet around the world, it is available in abundance in food and is the cheapest source of energy.

The p≤0.05 value was significant compared to proteins and lipids that did not reach significance, that is, the value of carbohydrates found in the analyzed menu is significantly lower than the PNAE recommended, according to the statistical analyses.

At this study, in 11-15 age range where the recommended value by PNAE is 65g of protein per capita, was found 41g per capita, which represents 98.46% of adequacy compared to the minimum recommended. Lower values were found in study realized by Silva & Gregório (2012) where the proteins showed 82.64% of adequacy for 11-15 years old students. And at the16-18 years old age range the recommended it is 80g per capita, since the provision of only 41g at the analyzed menu, showing 85.83% of adequacy of the recommendation.

According to Pecorari (2006) it is necessary a diet with appropriate protein content that works as the principal structural component of all body cells, including enzymes and hormones. For this reason it is primordial the adequacy of proteins offered in school feeding, including the study ages ranges of 11-15 and 16-18 years old that are contemplates by PNAE.

The lipid amount in the analyzed menu exceeded the recommendation for 11-15 years old students (10,9g) with 106.42% of adequacy and for 16-18 years old students the results reached 92.8% of the minimum recommended (12.5g), what agrees with the study realized by Silva & Gregório (2012) that found an higher adequacy percent for 11-15 years old students (132%) at the analysis realized at municipals schools in Taquaraçu de Minas.

Alimentary fibers also have an important role in our organism, performing various functions such as blood glucose regulation, blood cholesterol reduction, prevention and treatment of obesity and it also decreases the risk of cardiovascular diseases, diabetes and cancer (Vitolo, 2008). The study shows sufficient fiber levels for both age ranges, reaching a percentage of 7.38% above the minimum recommended for 11-15 years old students (6.1g) and for 16-18 years old students, it is observed a percentage of 2.34% above recommendation (6.4g).

Results higher than those found by Queiroz (2015), who analyzed 31 pre-school schools in the city of Assú / RN found that the fibers presented only 61% of the recommended values for PNAE. The lower acceptance of salads provided in the children's menu is one of the reasons for the low fiber consumption. In this study, it was observed that the beans are part of practically all the preparations, being rich in fiber, contributes to the percentage verified. According to Spinelli et al. (2003), the fibers are important components of the human diet, being that the soluble ones tend to delay the gastric emptying, and the insoluble ones only partially fermented in the large intestine, and with more specific action in the physical aspect, reducing the time of transit of the bolus in the intestine, increasing fecal mass and the ability to bind to certain nutrients and other compounds present in the intestine.

Micronutrients

Considering that adolescence is marked for several modifications, is extremely important the nutritional adequacy. Among the various functions, micronutrients are responsible for DNA synthesis, skeletal growth, sexual maturation and muscular and endocrine development (Giannini, 2007).

It was verified that the amount of vitamin A offered by the menu did not reach the recommendation, presenting a 74.48% adequacy result for students aged 11 to 15 years (140 μg) and 65.17% for students with ages ranging from 16 to 18 years (160 μg).The same occurs in the Caravajal, Koehnlein & Bennemann (2009) study, were they show that the menu served in a basic education municipal school in Maringá/PR did not reach the vitamin A recommendations, in which was found a percentage of only 14% of adequacy. However, Silva & Gregório (2012) found a percentage for 11-15 age range of 102.9% of adequacy. Among this many functions, vitamin A contributes for the tissue development and, together with iron, promotes erythropoiesis, making it difficult the appearance of anemia, very common in this period (Abranches et al., 2009).

Regarding vitamin C, the menu had 91.58% of adequacy for the 11-15 year age group and 78.5% for the 16-18 age group. Opposite results were found by Orué & Brecailo (2011), at the municipal school in Ponta Porã / MS, where the amount of vitamin C contained in the menu analyzed was above the PNAE recommendation (232.42% of adequacy).

Regarding magnesium, the offered amount was below recommendations for both ages, reaching a percentage of 60.49% of adequacy of recommendations for 11-15 years old (63mg) and 49.49% for 16-18 years old compared to PNAE recommendations (77mg). Silva & Gregório (2012) in a research on a municipal network schools in Taquaraçu de Minas was verified a similar result for students in 11-15 years old age range reached only 62% of the needs. Similar results were found by Azevedo et al. (2010), during an evaluation of a menu offered to 06-10 years old students in Governador Valadares/MG, where magnesium was below PNAE recommendations reaching only 46% of recommended. The magnesium perform a crucial role on activation of enzymatic system that regulates carbohydrates, proteins, lipids and electrolytes metabolism, acting on the integrity and transport of the membrane. Beyond that, it exerts influence in the mediations of muscular contractions and in the transmission of the nervous impulses (Azevedo, et al., 2010).

For zinc, the monthly meals exceeded the recommendations for both age ranges, 11-15 years old (325.56%) and 16-18 years old (293%). Lower results were found by Silva & Gregório (2012) for the 11-15 years old age range, 79%. The zinc has structural functions, catalytic and regulatory on cells, mainly as an intracellular ion, besides plays an important structural role as several proteins components. It also works in association with more than 300 different enzymes, in reaction involving the synthesis and degradation of carbohydrates, proteins, lipids and nucleic acids. The zinc also acts as an intracellular signal on brain cells, where it is stored in specific synaptic vesicles and is fundamental to the normal function of central nervous system. In addition to that, zinc is involved on the protein stabilization, the acid nucleic structure and in the integrity of sub cellular organelles, as well as in the transportation process, immunologic function and gene expression (Gallagher, 2012).

The menu was inadequate for the amount of calcium offered for the two age groups (28.37%). Lower values ​​(12.4%) were found by Conrado & Novello (2007) who analyzed the school meals offered to 353 students from the first to fourth grade of elementary education, from two schools of the municipal education network of the municipality of Inácio Martins / PR . Calcium deficiency and its persistence throughout life can lead to osteoporosis. In children, the low calcium intake can cause rickets, since, at this stage of life, the bones are in an intense remodeling process and the mineral needs are increased due to the growth process. Other signs of disability include muscle cramps and muscle pain (Conrado & Novello, 2007). Since the contribution of this mineral is inadequate, negative responses may affect the development of children, especially in the growth spurt period, which will occur later in adolescence. Thus, it is important to ensure minimal calcium intake for complete bone growth and maturation (Abranches et al., 2009).

As for iron, in both age groups was not adequately offered on the menu. A adequacy rate of 86.19% was observed compared to the recommendation for students aged 11 to 15 years (2.1mg) and 36.19% for students aged between 16 and 18 years (2.6mg). Higher results were found by Carvajal, Koehnlein & Bennemann (2009) and Abranches et al. (2009). It is essential for all living cells to participate in the metabolic pathways, being essential in the Krebs cycle, helping in the synthesis of DNA and other enzymatic systems. Both their excess and their deficiency can be harmful to the organism, and the adequacy of iron is necessary to maintain body homeostasis (Andrews & Bridges, 1998).

Conclusion

The offered menu for the school feeding in the study County does not reach, mostly, the PNAE recommendations for students in the 16-18 years old age range, being partially insufficient for those in 11-15 years old regarding the caloric content, carbohydrates, calcium, iron, magnesium, vitamin A and vitamin C. On the other hand, the values for lipids, fibers and zinc exceeded the minimum quota of the recommendation for both ages range. The large zinc amount observed constitutes a favorable finding, because this mineral is a structural and/or functional component of several enzymes, participates in a large number of cellular metabolism reactions, including physiological process such as immune function, antioxidant defense, grow and development.

It is evident that there is a need for differentiation in the determination of the per capita amounts between the different age ranges in other to better attend the PNAE recommendations.

References

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Diet In Childhood as an Obesogenic Environmental Factor: Current Evidence and Challenges

Raquel Leitão

College of Education at Politechnic Institute of Viana do Castelo. Research Centre on Child Studies; Viana do Castelo, Portugal

Abstract

More than a decade ago, a panel of experts has issued a strong warning - "Unless we can achieve changes at national and community as well as at individual levels, the present epidemic of obesity and overweight seems likely to continue until overweight is the norm" (Burniat, Cole, Lissau, Poskitt, 2002, preface). Unfortunately, although there are signs of stabilization in certain geographic areas, current data for countries of the WHO European Region indicate that one in three children aged 11 years is overweight or obese. These revelations are concerning because of the unequivocal negative impact that obesity has at clinical, psychosocial and economic level, but also because several studies suggest that the likelihood of reaching the targets set for 2025 is virtually zero. Under a holistic perspective, the present analysis focuses on children’s diet as an environmental factor promoting obesity, that is, obesogenic, through the discussion of key aspects ranging from globalization to food and nutrition environment in the first years of life. The recognition of these factors, and understanding how they can limit individuals' opportunities to make the food choices that benefit them, are most critical to overcoming barriers to effective prevention and treatment of obesity, which persists as both a major public health problem and as one of the most important societal challenges in the 21st century.

Keywords:diet, childhood, obesogenic environment

Introduction

The idea that diet and nutrition play a decisive role in health and disease is not new. Already in distant past there was this recognition as indicated by descriptions of Hippocrates (460 - 375 BC) such as "... that your food be your only medicine; May your only medicine be your food! ...” or of Celso, who in the first century stated "...the best medicine is the food given in due course". After several centuries, the concept of preventive nutrition emerges refreshed by Blumberg (1997), reinforcing that the most important choice people can make to influence their long-term health prospects is the choice of diet.

Diet, in addition to supplying the organism with the substances that support it in its existence, promoting growth, restoring losses, and providing energy, as well as the effects it has on health maintenance and disease prevention, is intrinsically linked to the diversity of cultures and to all that contributes to model the identity of each people (Montanari & Flandrin, 1996). When studying food patterns with ancestral origins, one can even conclude that food encompasses knowledge, skills, practices, representations, expressions, places and objects built and recreated historically over thousands of years in an intimate relationship between populations and nature (Dernini, 2011). However, as the historians cited above point out, diet is also profoundly influenced by new lifestyles. In the past century, one of the most significant changes in society is the one seen in food systems. As described in 2014 by the Global Panel on Agriculture and Food Systems for Nutrition, these systems cover production, processing, distribution, waste and food consumption, so that people have access to nutritious and reasonably priced food at all stages of life. Globalization, trade liberalization and rapid urbanization have been identified as the main factors influencing changes in food systems, which in turn largely explain changes in dietary patterns of populations (Gillespie & van den Bold, 2017). From the perspective of public health, globalization is also one of the socioeconomic, cultural, political and environmental determinants underlying the intermediate risk factors for the major chronic diseases in Europe, including obesity (EHN, 2011; WHO, 2017a).

Despite the strategies defined and measures implemented in recent decades by many countries to tackle obesity, and the signs of stabilization in certain geographical areas, the overall prevalence of this problem is high, has been increasing, and the likelihood of meeting the global obesity target set for 2025 is virtually zero (NCD-RisC, 2016; Ng et al., 2014). The dimension of excessive weight has reached 1.9 billion adults worldwide, of which about 600 million are obese (WHO, 2017b). Globally, overweight affects 42 million pre-school children and data for countries in the WHO European Region show that one in three children aged 11 years old is overweight or obese (WHO, 2017b). These findings are alarming because of the unequivocal negative impact that obesity has on clinical level, being associated with higher all-cause mortality (Di Angelantonio et al., 2016), but also at the psychosocial and economic level (De Niet & Naiman, 2011; Y. C. Wang, McPherson, Marsh, Gortmaker, & Brown, 2011). The presence of obesity in children raises particular concern since it is associated with adverse health effects even at a young age (Biro & Wien, 2010). Additionally, it exacerbates risk factors for chronic noncommunicable diseases in adult life, especially in children who do not have normal linear growth (Lobstein et al., 2015; Reilly & Kelly, 2011), and may persist throughout the lifespan (Leitão, Rodrigues, Neves, & Carvalho, 2011; Singh, Mulder, Twisk, Van Mechelen, & Chinapaw, 2008).

Obesity is described as the excessive accumulation of body fat at a level capable of compromising health, demonstrated by an increased risk of various diseases including cardiovascular disease, type 2 diabetes and some cancers (Danaei et al., 2009). Considering that in the genesis of this adiposity increase lies a continuous positive energy balance, in which the energy consumed exceeds the energy expended, the causes of obesity seem simple - food inadequacy and physical inactivity. So how can we justify the failure of measures to prevent and treat childhood obesity focused on education and individual behavioural change related to diet and physical activity? Effectively, the current body of knowledge about the determinants and mechanisms underlying this pathology is sufficient to demonstrate that such energy unbalance results from a complex interaction of several factors, not only behavioural, but also genetic, epigenetic and environmental ones (Pigeyre, Yazdi, Kaur, & Meyre, 2016; B. A. Swinburn et al., 2011; van Vliet-Ostaptchouk, Snieder, & Lagou, 2012; Yoon & Kwon, 2014). As such, individuals might develop obesity as consequence of the susceptibility conferred by their genetic characteristics when they are exposed to an "obesogenic" environment (Whitaker, 2002). By definition, the obesogenic environment consists of the sum of influences of the surrounding physical environment, the opportunities, or the living conditions that promote obesity in individuals or in populations (B. Swinburn, Egger, & Raza, 1999). In other words, it refers to the environment that comprises the full range of social, cultural, and infrastructure conditions that affect the individual's ability to follow a healthy lifestyle. More recently, the term "obesogenic" has been proposed to refer to all environmental factors and dietary, pharmaceutical and industrial compounds that play a potential role in the development of obesity by influencing the number and/or size of adipocytes, the hormones regulating appetite and satiety, as well as food preferences and energy metabolism (Skinner, Manikkam, & Guerrero-Bosagna, 2011). The analysis of these descriptions again points to changes in the global food system, as they appear to be the main common factor driving the simultaneous increase in the prevalence of obesity in a very broad set of countries (B. A. Swinburn, et al., 2011). As the above-mentioned authors warn, the current food system is characterized by the production of ultra-processed, cheap and more effectively marketed foods than ever before, which leads to passive and excessive energy intake, and consequently obesity. Furthermore, in parallel with the growing preponderance of 'fast food', there is a gradual loss of 'traditional cuisine' based mainly on unprocessed or minimally processed foods (Monteiro, Levy, Claro, de Castro, & Cannon, 2011).confirm that you have the correct template for your paper size.

Relashionship Between the Nutritional Environment and Childhood Obesity

It could be considered that the above-mentioned problems would only affect children from an age when they already have some autonomy to make their food choices, either by voluntarily consuming food to which they have access at home and school, or, for example, by the request of certain foods when shopping with parents in the supermarket. Therefore, in the first years of life, children would not be vulnerable to the negative effects of excessive consumption of foods with high energy density and low nutritional density, typical of a wide variety of ultra-processed foods. However, this is not the case. Exposure to nutritional environment begins very early, even from the intrauterine life, either by the influence of mother’s nutritional status on foetus growth and development, or through her eating habits during pregnancy, continuing during childhood and adolescence (Frihauf, Fekete, Nagy, Levin, & Zorrilla, 2016; Godfrey & Barker, 2000; Spencer, 2012; Vickers, 2014; Williams, Mackenzie, & Gahagan, 2014).

Gestation

Birth weight has been one of the most investigated somatic characteristics in relation to these described influences, since it is an important indicator of prenatal development conditions. Although the influence of genetic factors on birth weight is recognized, results from research have suggested that gestational weight gain is a potential risk factor for childhood obesity (Lau, Liu, Archer, McDonald, & Liu, 2014). Moreover, regardless of the pre-gestational body mass index of the mother, weight gain during pregnancy is directly associated with the child's adiposity at birth (Starling et al., 2015). In turn, babies with high birth weight are more likely to develop obesity, as indicated by several studies based on different methodologies (Qiao et al., 2015; Yu et al., 2011). This risk may be related to changes in appetite control, neuroendocrine function and energy metabolism, resulting from foetal overnutrition (Lawlor & Chaturvedi, 2006). Although not consistent in the literature, some studies also suggest an association between low birth weight and increased risk of obesity (Schellong, Schulz, Harder, & Plagemann, 2012; Stout, Espel, Sandman, Glynn, & Davis, 2015; Yu, et al., 2011). A possible explanation for this relationship is that foetal malnutrition will "program" the metabolism to an energy "saving" system, which may predispose to obesity, especially if the child is exposed to overnutrition (Rolland-Cachera, Deheeger, Maillot, & Bellisle, 2006).

Breastfeeding and infant formulas

The influence of dietary factors on growth during the first year of life has been widely studied, with special emphasis on breastfeeding, which, as evidenced by numerous epidemiological studies, is associated with the prevention of obesity in childhood and adolescence (Gillman, Rifas-Shiman, Camargo, Jr, & et al., 2001; Scott-Jupp, 2017; Yan, Liu, Zhu, Huang, & Wang, 2014). When compared to formula-fed children, those who are breastfed have a 20% reduction in the likelihood of being obese at school age (Koletzko, von Kries, Monasterolo, et al., 2009). On the one hand, this association can be explained by the fact that breastfeeding induces lower plasma insulin levels and consequently reduces the adipose reserve and prevents early adipocyte development. (Oddy et al., 2014). On the other hand, according to these authors, the higher protein content of infant formulas, as compared to breast milk, is responsible for the increased growth rate and adiposity during the period of influence in which infants are formula-fed. Indeed, the hypothesis that high protein intake in the first years of life is a risk factor for the development of obesity has been strengthened (Michaelsen, Larnkjær, & Mølgaard, 2012). Even when the research focuses on comparing different infant formulas, it turns out that the intake of those with lower protein content is associated with lower weight up to age 2 years, as demonstrated in a randomized clinical trial (Koletzko, von Kries, Closa, et al., 2009). The equations are an exception to the prescribed specifications of this template. You will need to determine whether or not your equation should be typed using either the Times New Roman or the Symbol font (please no other font). To create multileveled equations, it may be necessary to treat the equation as a graphic and insert it into the text after your paper is styled.

Complementary feeding and food’s energy density (ED)

Complementary feeding, the transition period from exclusive milk (human or formula) to family foods, is a vulnerable period when other nutritional factors that may modify the risk for the development of obesity, such as energy density (ED), emerge. This food property (ED) refers to the energy available per unit of weight (Kcal/g), which can be calculated for food, meals and the total diet (Vernarelli, Mitchell, Rolls, & Hartman, 2013). Apparently having a major influence on the regulation of food intake and body weight, ED is now considered an indicator of diet quality (Drewnowski, 2003). In the last decades, the increasing consumption of high energy-dense foods has come to draw attention due to the potential relation with the increasing prevalence of childhood obesity. For that reason, many entities such as the WHO, the American Academy of Paediatrics or the Portuguese Association for Nutrition, formerly called Portuguese Association of Nutritionists, recommend the restriction of energy-dense foods intake in children along with a higher consumption of fruit, vegetables and dairy products as an important way for preventing obesity. Although more studies are needed to clarify the association between ED and childhood obesity, in a study involving a nationally representative sample of 2442 U.S. children aged 2–8 y it was found that obese children had a higher dietary ED than lean children (Vernarelli, Mitchell, Hartman, & Rolls, 2011). In this study, high ED was associated with greater intakes of energy, fat and added sugars, and with significantly lower intakes of fruits and vegetables.

Added sugars intake

In addition to fat, the macronutrient with the highest ED (9kcal/g), the high amount of sugars (monosaccharides and disaccharides) added by the food industry to processed foods also has a strong influence on dietary ED. When this occurs in foods specifically intended for babies and young children, the problem becomes even more worrying. In this context, it is essential to distinguish between simple carbohydrates (sugars) and complex carbohydrates, of which starch stands out. Research has shown that this complex carbohydrate, starch, particularly in the form of resistant starch and slow absorption starch, has beneficial effects on digestion, absorption and metabolism, favouring glycaemic curves and insulin sensitivity, which in turn is associated with better regulation of the hunger/satiety mechanism, among others mechanisms (Aller, Abete, Astrup, Martinez, & van Baak, 2011).

In Europe, the compositional criteria for infant and follow-on formulae, as well as other foods for infants and young children, is established in EU Directives. As example, infant formulae shall have a minimum of 9g of total carbohydrates/100kcal and a maximum of 14 g/100 kcal, when reconstituted as instructed by the manufacturer. For cereals, if sucrose, fructose, glucose, glucose syrups, or honey is added, the amount of added carbohydrates shall not exceed 7.5g/100kcal and the amount of added fructose shall not exceed 3.75 g/100 kcal (Stephen et al., 2012).

For both adults and children, WHO strongly recommends reducing the intake of free sugars to less than 10% of total energy intake, and also suggest that a further reduction of the intake of free sugars to below 5% of total energy intake could the associated with health benefits (WHO, 2015). As defined by the WHO, “free sugars” include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. The American Heart Association recommends that children aged <2y should avoid the consumption of added sugars.

The existing food composition regulations, guidelines and health recommendations, although of great importance, do not seem to be sufficient to guarantee an adequate intake regarding amounts and types of carbohydrates, as well as other food components. Most commercial toddler meals, cereal bars and breakfast pastries, and infant-toddler snacks and desserts in the United States contain added sugars or have high sodium (Maalouf et al., 2017). Similarly, in a research on baby and toddler food products sold in Canada it was found that 63% of products have either high levels of sodium or an excessive proportion of calories coming from sugar (Elliott, 2011). These findings led the cited authors to conclude that baby and toddler foods were not found to be nutritionally superior, in terms of sodium or sugar, to their adult counterparts, and that these products are clearly of concern and should be closely monitored, since they promote a taste for 'sweet' and 'salty' at a young age. Recent data for several European countries (Belgium, France, Denmark, Hungary, Ireland, Italy, Norway, Netherlands, Spain and the UK) confirm that intakes of total and added sugars are globally high and point to sweet products and beverages as the major contributors to added sugar intakes (Azais-Braesco, Sluik, Maillot, Kok, & Moreno, 2017). Of particular relevance is the fact that relative intakes observed in this last study were higher in children than in adults, with total sugars ranging between 15 and 21% of energy intake in adults and between 16 and 26% in children.

Food advertisement directed to children has been described as an important factor contributing to the increasing intake of high energy-dense foods, sugar and/or salt (Rodrigues, Carmo, Breda, & Rito, 2011). In turn, the intake of energy-dense, nutrient-poor food and beverages, as a result of a changing environment, is linked to childhood obesity (Perez-Escamilla et al., 2012; Sonntag, Schneider, Mdege, Ali, & Schmidt, 2015). However, the influence of the food industry on obesity-related dietary behaviour among children is complex and it is associated with different contexts. A recent systematic review has revealed six key obesogenic environments by which this influence can occur: schools, retailers, mass media “television”, mass media “internet”, promotional campaigns and home (Sonntag, et al., 2015).A minimum of one author is required for all conference articles. Author names should be listed starting from left to right and then moving down to the next line. This is the author sequence that will be used in future citations and by indexing services. Names should not be listed in columns nor group by affiliation. Please keep your affiliations as succinct as possible (for example, do not differentiate among departments of the same organization).

Home environment

The home and family environment assumes an unquestionable role at the first years of life, particularly if taking into account how children learn to eat as well as the consequences of this process on dietary patterns, growth and health. In fact, individual patterns of food preferences and eating behaviours emerge and differ depending on the foods offered and on the contexts of feeding during the early period of dietary transition from birth to age 2y (Birch & Doub, 2014). According to these authors, the development of children’s eating behaviour and food preferences occurs by three ways: (1) familiarization, (2) associative learning, and (3) observational learning. Through these processes, and driven by biological determinants, children learn what, when, and how much to eat based on the transmission of cultural and familial beliefs, attitudes, and practices surrounding food and eating. By the time they reach 2y of age, children`s diet becomes similar to those of other family members (Birch & Doub, 2014; Savage, Fisher, & Birch, 2007). Thus, as example, if parents do not eat vegetables, what to expect from children´s food habits regarding these healthy foods? See that current evidence reveals that the prevalence of fruit and vegetable consumption is still lower than desired across the lifespan (Franchini, Poinhos, Klepp, & Vaz de Almeida, 2013; Miles & Siega-Riz, 2017; Vereecken et al., 2015; X. Wang et al., 2014) though it is associated with a lower risk of all-cause mortality, particularly cardiovascular mortality (X. Wang, et al., 2014). The potential intergenerational transmission of unhealthy eating habits raises great concern in an increasing obesogenic environment, which can include the home environment. In fact, a research study involving 2402 families from the UK showed, as expected, that composite measures of the obesogenic home environment are associated with diet, physical activity, and TV viewing (Stephanie Schrempft, van Jaarsveld, Fisher, & Wardle, 2015). Moreover, other recent study using a novel composite measure of the home environment revealed that families who are more socio-economically deprived, and where the mothers are themselves heavier and have a more food responsive eating style, tend to provide a home environment with the hallmarks of a higher risk of weight gain (S. Schrempft, van Jaarsveld, Fisher, Fildes, & Wardle, 2016).

Conclusion

Food and nutrition environment is a major component of the obesogenic environment, with children being particularly vulnerable to its impact from as early as life in utero. In consequence of globalization, trade liberalization and rapid urbanization, changes in food systems are causing important modifications in dietary patterns and eating habits. Current evidence shows that several nutritional key aspects such as gestational weight gain, infant and follow-on formula composition, and free sugars intake, are linked to childhood obesity. Home is among potential obesogenic environments, which is of great concern given the influence of parents on children´s eating habits. Preventing obesity by promoting healthier lifestyles requires the recognition that food choice goes far beyond a simple individual behaviour. It is complex and influenced by multiple factors interacting at physical and social environment level as well as at general policy level. Thus, strategies to counteract obesity involves better policies regulating foods systems, trade, media advertising, transport and urban design. Together with greater investments in health education and primary health care, these efforts should help shape the environment so that the healthiest choices become the easiest to make.

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Chapter 5

Pediatrics

Which Adolescents Come to the Emergency Department? – Study of a Level III Hospital

Marta Isabel Pinheiro, Vanessa Gorito, Cristina Ferreras, Mayara Nogueira, Ana Maia

Pediaric Medical Services - Integrated Pediatric Hospital, São João Hospital Center, Porto, Portugal

Afonso Pedrosa

Software Development Unit, São João Hospital Center, Porto, Portugal

Almeida Santos

Pediaric Medical Services/ Peidatric Emergency Services - Integrated Pediatric Hospital, São João Hospital Center, Porto, Portugal

Abstract:

The increase of pediatric care up to the age of 18 resulted in new needs, approaches and pathologies in the Pediatrics’ Services. The Pediatric Emergency Department (PED) is often the first contact of the adolescent with medical care, so the pediatrician needs specific training in this population.

The aim of this study was to analyze the adolescents that came to the PED of a level III Hospital in 2015, through the retrospective and descriptive analysis of the visits data in the PED software.

Adolescents represented 34.5% of PED episodes (26 408 visits). The median age was 14 years and 50.5% were female. The main causes of attendance were acute illness (61.9%) and school accidents (18.1%). The majority (87.0%) was discharged without a referral, 3.6% were admitted, 2.6% were oriented to primary health care, 2.3% to an outpatient visit, 1.7% to other hospital and 1.7% left without discharge. The most common reasons for adolescent visits to PED were musculoskeletal, digestive and dermatological symptoms. The most frequent medical diagnoses were: injuries and poisonings; symptoms, signs and ill-defined conditions; diseases of the musculoskeletal system and connective tissue.

Adolescent care was an expressive percentage in the PED, higher to that described in other centers. Respiratory and digestive pathology dominated PED visits in other studies. Periodic analyses are needed to assess the specificities of each age group, thus improving the training of emergency staff and care provided.

Keywords: Adolescents; Emergency Department; Canadian Triage; Pediatrics

Introduction:

The increase of pediatric care up to the age of 18 in Portuguese health services occurred gradually at Pediatric Urgency of Porto (PUP) based on the Centro Hospitalar de São João, in January 2010 (Araújo, 2010), and led to an increase in pediatric population, resulting in new needs, approaches and pathologies. This was a challenge for the Pediatric Services previously prepared to attend until the age of 13 (Madureira, Santos, & Moleiro, 2008). According to World Health Organization, adolescence is the period from 10 to 19 years, usually a healthy age group (Prazeres, 2005).

The Pediatric Emergency Department (PED), although directed to urgent/emergent acute situations (Oliveira, Pires Guerra, Cunha, Peralta, Almeida & Bicho, 2010), is often the first choice of the adolescents. Therefore the pediatrician must know their particularities and need specialized training to attend this population.

The present study aimed to characterize the visits of adolescents to the PUP (Level III Hospital and reference for traumatology, neurocritical patients and congenital heart diseases) in 2015.

Methods

Retrospective and descriptive analysis of all episodes recorded in PUP’s software (jOne®) regarding patients with ages between 10 to 17 and 364 days who attended the PED between January and December 2015.

The following data was recorded: demographic variables – gender, age and county; date and provenance – outside, primary health care (HC), Portuguese National Institute of Medical Emergency (INEM), private clinic, external consultation, “Saúde 24”, other Hospital/urgency, hospital admission, operating room or day hospital. The level of priority of care was given according to Canadian Triage and Acuity Scale Pediatric which defines “level I” as emergent, which needs immediate care, “level II” as a need for care in 15 minutes, “level III” as urgent situation with care in 30 minutes, “level IV” less urgent situations (60 minutes) and “level V” non-urgent situations (Canadian Association of Emergency Physicians, 2010).

For each patient, the reason for PED visit was accessed by administrative group: disease, accident, aggression, pregnancy, intoxication, tumble, burn or violation; and by the complaint reported to the triage’s nurse through the algorithm used. The initial orientation of the patient to different specialties (Pediatrics, Pediatric Surgery, Pediatric Cardiology, Orthopedics, Otorhinolaryngology (ENT), Ophthalmology, Gynecology, Obstetrics, Stomatology, Neurosurgery, Plastic Surgery and Immunohemotherapy) was also accessed. The medical diagnosis attributed was based on the 9th revision of the International Classification of Diseases (ICD-9-CM), in use in 2015. The destination of each adolescent was also reported: external not referenced, HS, outpatient visit, admission, another hospital, death or left the PED against medical opinion. The readmission situations were registered as another visit to the PED in a period of 5 days after clinical discharge. The authors were authorized to the computer data and ensured their confidentiality. The data were statistically analyzed by Microsoft Excel 2010® software.

Results

During the study period, there were 26 408 adolescent visits, representing 34.5% of the total PUP visits in 2015 (76 566). The median age was 14 and 50.5% was female. The number of visits during the year had no significant variations, with August being the month with the lowest number of visits (6.0%), against October and November, with 10.2% monthly. On the other hand, during the week Monday was the day with the greatest affluence (16.4%). The counties nearest to the hospital contributed with the highest number of visits: Porto (n=6052, 22.9%), Gondomar (n=5250, 19.9%), Matosinhos (n=4444, 16.8%), Maia (n=4054; 15.4%), Valongo (n=3165, 12.0%) and Vila Nova de Gaia (n=614, 2.3%). Most patients came to PED without referral (86.8%, n=22 918), 5.2% (n=1379) were referred from HC, 3.6% (n=961) from another Hospital, 2.5% (n=655) from INEM, 1.2% (n=310) from “Saúde 24”, 0.6% (n=156) from private clinics, 0.1% (n=25) from outpatient visits, two patients came from Pediatric Service, one from the day hospital and another from the operating room. The patients came mainly due to illness (61.9%) and school accidents (18.1%), as shown in Figure 1.

Figure 1 . Reasons (administrative) for going to PUP (n; %)

After applying the priority screening method, “level I” was assigned in 0.1%, “level II” in 4.0%, “level III” in 24.7%, “level IV” in 65.7% and “level V” in 5.5%. It should be noted that 91.5% of “level IV” patients and 92.5% of “level V” were adolescents who came without a referral (86.8%).

Of all visits, 48.0% (n=12 689) were initially seen by Pediatrics, followed by Pediatric Surgery (n=9457, 35.8%), Orthopedics (n=2310, 8.7%), Ophthalmology (n=960, 3.6%), ENT (n=518, 2.0%), Stomatology (n=228, 0.9%), Gynecology (n=120, 0.5%), Obstetrics (n=76, 0.3%), Immunohemotherapy (n=25, 0.09%), Pediatric Cardiology (n=16, 0.06%), Neurosurgery (n=5, 0.02%) and Plastic Surgery (n=4, 0.02%).

The most reported symptoms in PUP (screening by the algorithm used) are listed in Table 1, being the musculoskeletal and digestive the most representative.

The diagnostic groups of the patients are summarized in Table 2, the pathologies of group XVII – "Lesions and poisonings" – were the most frequent. Abdominal pain (n=273), concussion-except cerebral (n=194), acute gastroenteritis (n=153), alcohol/drug abuse (n=144), anxiety state (n=123) and tonsillitis (n=113) were the most coded diagnoses.

The majority of patients (n=22 988; 87.0%) was discharged without any referral, 3.6% (n=947) were admitted, 2.6% (n=699) were oriented to their HC, 2.3% (n=617) to an adolescents outpatient visit or another specialized area, 1.7% (n=462) were transferred to another hospital and 1.7% (n=436) abandoned PED against medical opinion; two deaths were certified and one adolescent was referred to a Continuous Care Unit. Due to a computer error, in approximately 1% of visits there is no record of destination. About 5% (n=1325) of the patients came back to PUP within a period up to 5 days.

Discussion

Adolescent care was an expressive percentage in the PED (34.5%), being superior to that described in other hospitals which ranged from 15 to 16% (Madureira et al., 2008; Quintas, Pequito & Fonseca, 2003; Ziv, Boulet, & Slap, 1998). This high rate could be explained by a less than expected use of Primary Health Care, considering the symptoms and diagnosis data. The appropriate use of available resources could probably prevent the overcrowding of the PED, decreasing the waiting times.

In other Portuguese studies, the respiratory and digestive pathology were the main reasons to go to the PED (Caldeira, Santos, Pontes, Dourado, & Rodrigues, 2006; Oliveira, Pires Guerra, Cunha, Peralta, Almeida & Bicho, 2010), although the methodology used was not always comparable. In these studies, accidents, poisonings and injuries were still considerable causes of visits to the Emergency Department.

Adolescence is a period of physical, psychological and behavioral changes (Ziv, Boulet, & Slap, 1998). It is expected a higher prevalence of complaints and pathologies distinct from other age groups, for example, social and behavioral problems were reasons relatively frequent in the present study, reminding us of the need of active, updated and empathic pediatricians. The recent implementation of the Adolescents outpatient visit, in the Integrated Pediatric Hospital of the Centro Hospitalar de São João, allowed guiding many of them for a trained and regular follow-up.

The limitation of the present study was the absence of a temporal evaluation, making evolutionary comparisons impossible.

Periodic analysis will be necessary to characterize the population that attends the PED and evaluate the specificities of each age group, allowing the improvement of emergency staff training and, consequently, the improvement of the care provided. The elaboration of protocols and recommendations, the promotion of updating actions and the adaptation of the physical conditions of the PED for this age group are still important steps.

References

I. Araújo, F. (2010). Orientação Clínicas, Urgência Pediátrica do Porto. 1st edition. Porto: UPIP.

II. Madureira, N., Santos, R., & Moleiro, P. (2008). Os adolescentes no Hospital de Santo André: que necessidades de saúde. Acta Pediatr Port, 21, 547-552.

III. Prazeres, V. (2005). Bases do Programa Nacional de Saúde dos Jovens: Direcção-Geral da Saúde, Divisão de Saúde Materna, Infantil e dos Adolescentes.

IV. Oliveira, A., Pires Guerra, M., Cunha, F., Peralta, L., Almeida, S. & Bicho, A. (2010). Serviço de Urgência Pediátrico: casuística de um hospital com serviço de Pediatria Geral. Saúde Infantil, 32 (2): 53-58

V. Canadian Association of Emergency Physicians (2010). Canadian Paediatric Triage and Acuity Scale: Implementation Guidelines for Emergency Departments. Canadian Journal of Emergency Medicine. Retrieved Dec 2015, from http://www.cjem-online.ca/v3/n4/PaedCTAS

VI. Ziv, A., Boulet, J. R., & Slap, G. B. (1998). Emergency department utilization by adolescents in the United States. Pediatrics, Pediatrics, 101(6), 987-994.

VII. Caldeira, T., Santos, G., Pontes, E., Dourado, R., & Rodrigues, L. (2006). O dia-a-dia de uma urgência pediátrica. Acta Pediatr Port, 1(37), 1-4.

VIII. Quintas, F., Pequito, M. & Fonseca, H. (2003). Alargamento da Idade Pediátrica no Serviço de Urgência de Pediatria - Um Novo Desafio. Acta Pediatr Port., 5; 34: 339-343

Hospitalized Adolescents in a Pediatric Service – Analysis of a Level III Hospital

Vanessa Gorito,

Marta Isabel Pinheiro, Cristina Ferreras,

Sara Fonseca, Lara Lourenço,Ana Maia

Pediaric Medical Services - Integrated Pediatric Hospital, São João Hospital Center, Porto, Portugal

Abstract

Introduction: The extension of the pediatric age until 18 years old, demands a well-directed and specific approach, as well as the instruction of the Pediatricians.

Objectives: Determinate the relevance of the age range of adolescence (10 to 18 years) in the internment of pediatrics, between 2010 and 2015. Characterize the hospitalized adolescences in the year of 2015, in C.H.São João- Oporto.

Methodology: The total number and proportion of hospitalized adolescences was analyzed. The following variables were evaluated: sex, age, provenance, nosological group (ICD9), duration of hospitalization and guidance after discharge.

Results: In 2010, adolescents were responsible for ≈23% of hospitalizations and 33% in 2015. In 2015, 63.4% were male and the median was 14 years. About 66.3% were hospitalized through emergency department and 30% through the outpatient care. The major pathological groups responsible for hospitalizations were: Digestive System Diseases (35%); Genitourinary System Diseases (8%); Skin and Subcutaneous Tissue Diseases (7%); Nervous System Diseases (6%). The hospitalizations were mostly short: ≈40% with duration ≤ 24 hours and 16% of two days, the majority (81%) was of the district of Porto. After discharge, 74% were consulted and 13% were assisted. The mortality rate was <0.2%.

Discussion: Adolescents constitute an important and growing percentage of children's hospitalizations. The 30% of hospitalizations by the consultation alert to the importance of chronic diseases at this age. It is important to characterize them to adapt the monitoring and prevention, using Adolescent Consultations and adaptation of the conditions of hospitalization.

Keywords: Adolescents, hospitalization, pediatrics

Introduction

Adolescent mortality exceeded the number of deaths compared to any other age group in Pediatrics, regardless of whether they were developed or developing countries (1), having the WHO (World Health Organization) identified the health of the adolescent as a priority problem of global health. (2) One of the possible justifications for this is the limitation in identifying the specific needs of adolescents, often culminating in pathology in the short or long term. (3) (4)

The widening of the pedriatric age to 18 years is associated with a greater diversity of pathologies with an increasing recognition of the central role that adolescents play in culture and society. Building a global and effective workforce of highly qualified health professionals who understand the unique biological, psychological, behavioural, social and environmental factors, that affect adolescent health, is a critical step in meeting the health needs of the growing youth cohort (5)

Although adolescents are considered to be a healthy population, the truth is that they have specific needs and problems that require a targeted approach, often with a need for hospitalization. (6) The advantage of having Adolescent Consultations is consensus among Pediatricians and it is urgent to reflect on the need for exclusive units / hospitalization areas for this age group that allow separation by sex and age, something that does not happen nowadays, whose advantage is not yet unanimously accepted. (7)

In this sense, several international studies have been carried out on the adolescent population hospitalized in the Pediatric services, in order to better describe and consequently guide these patients. An Australian study about the profile of adolescents hospitalized in the Pediatric Services, describes a growing percentage of hospitalized adolescents, reaching 30%, thus justifying the development and planning of strategies to better balance physical and psychological priorities at this specific age. (8) Some hospitals, notably in the United Kingdom and Australia, have recently been planning to integrate patients from this age group into pediatric hospitalization by building new buildings and / or adjusting pre-existing buildings for this new reality. (9)

Nowadays the idea of the need of specialized medicine in the adolescent is already diffused, particularly by the important psychosocial component that is inherent to it. (10) Ideally, this approach should start even in medical schools, thus preparing health professionals for the requirements of this age group. (11)

Objectives

In order to obtain data to better discuss this issue, we proposed to determine the relevance of the adolescence age range (10 to 18 years) in the Pediatric Hospital - Integrated Pediatric Hospital of the Hospital Center of São João, in the period between January 1 of 2010 and December 31 of 2015. As a second objective, we outline the characteristics of adolescents hospitalized during the year 2015 (January 1 to December 31).

Methods

A retrospective study was carried out in the field of descriptive statistics, which included all individuals aged between 10 years and 17 years and 364 days admitted to the Integrated Pediatric Hospital - Pediatric Service of S. João Hospital – Oporto. Patients admitted to observation in the Emergency department weren´t included.

The total number and proportion of hospitalized adolescents were determined, since the extension of the admissions until the age of 18 years in 2010.

All admitted adolescents from 2010 to 2015, were analyzed in order to determine the evolution and proportion of the number of hospitalized adolescents, in relation to total hospitalizations during this period.

It was also decided to characterize the adolescents in the year 2015, using hospital informatic codification, regarding the variables: sex, age, provenance, nosological group (ICD9 classification), duration of hospitalization and post-discharge orientation to better study their evolution over this period.

Data analysis and statistical treatment were performed, using the software -Statistical Package for the Social Sciences (SPSS, version 19) as well as Microsoft Excel.

Results

Since the Pediatric Service extended the maximum age of admission to the age of 18, there has been a gradual increase in hospitalized adolescents in relation to the total number of hospitalizations. In 2010, adolescents were responsible for almost 23% of hospitalizations; in 2011 approximately 27%; in 2012 they increased by 0.9% in relation to the previous year; in 2013 they exceeded 30%; in 2014 there was an increase of about 2.5% compared to 2013 and in 2015 they exceeded 33% (Table 1).Table 1: Pediatric hospitalization evolution (2010-2015)

In relation to 2015, we counted 1159 admissions between the age of 10-18 years; 63.4% were male. The median age was 14 years (P25 = 12, P75 = 16) with an average of 13.8 years. About 55.4% of admissions were from adolescents between the ages of 14 and 18 years. Around 28.1% of all adolescents had at least 16 years.

Regarding provenance, according the data available, the majority (~66%) were admitted through the Emergency Department, but an important percentage (~31%) was hospitalized through the outpatient appointment. There were 9 hospitalizations, per transfer from other health units of the National Health System, 2 came from private units. Thirteen patients were referenced by assistant pediatrician (Table 2).

Table 2: Hospitalization provenance

The main pathological groups responsible for hospital admissions, according to the nosological classification provided by the ICD9 were: Digestive System Diseases (35%); Diseases of the Genito-Urinary System (8%); Skin and Subcutaneous Tissue Diseases and Endocrine Gland Diseases (7%), Nervous System Diseases (6%); Diseases of the Respiratory System and Congenital Malformations (5%); Infectious and Parasitic Diseases, Circulatory System Diseases and Diseases of the Blood and Hematopoietic Organs (4%) (Table 3). Around 27% had chirurgic pathology and about 12% had chronic diseases which motivated more than one admission per year.

Table 3: Main nosological groups (ICD9) responsible for the hospitalizations of 2015

Most hospitalizations were short: ≈40% (n = 400) lasting ≤ 24 hours and 16% (n = 164) of two days. Regarding the geographical area, the majority of patients admitted belonged to the Porto district (~81%). The other districts with the highest hospitalization rates were: Braga (5.55%); Aveiro (4.46%) and Vila Real (2.28%).

After discharge, 74% were orientated to an outpatient appointment. Around 15% were orientated to a primary care physician. About 10% were referred to other hospitals and less than 1% were discharged against medical decision (Table 4).

Table 4: Orientation after discharge

The mortality was less than 0,2%.

Discussion

Adolescents constitute an important and growing proportion of hospitalizations in Pediatric services, with a considerable increase in older adolescents hospitalized. Even though they are mostly short-term hospitalizations, adolescents are currently responsible for about one-third of hospitalizations in our center. This gradual increase over the years should leave us alert to a new reality to be experienced in Portuguese hospitals and by health professionals, which is already happening all over the world, being the numbers obtained in line with data published in other countries that also show increasing hospitalization rates, around 30%. (8)

The fact that 30% are admitted through outpatient care clinics, warns of the importance of chronic diseases at these ages, as opposed to the generalized idea that this age group refers to healthy individuals, according to available literature. (3) (4)

Regarding the causes of hospitalization, comparing our results with another retrospective and descriptive study performed by Dougal and Russel, at an English Hospital between the period of 1999-2010, some similarities among the results obtained were found. In this study, the main reason for hospitalization are of obstetric causes, equivalent in our description to diseases of the Genito-Urinary System (second most important reason for our admissions). According to Dougal and Russel, digestive diseases had increased almost 50% during that period. Comparing with our results, diseases of the digestive system are the most frequent causes of hospitalization, responsible for about a third of our admissions. (12)

It is important to characterize correctly this population, so that we can adapt to their physical and psychological needs and demands, in order to develop a targeted intervention.

The authors consider it fundamental to carry out groundwork, following-up and prevention, valuing adolescent appointments, in which it will be possible to work specifically for the target population, with directed professionals who will be able to complement their training in this area and thus provide a more directional care. (10) (11)

It is also necessary to adapt the conditions of hospitalization, that make it possible to separate by age and sex, a gap still to be filled in the reality of most Portuguese hospitals.

References

I. Viner RM, Coffey C, Mathers C, et al. 50-year mortality trends in children and young people: a study of 50 low-income, middle-income, and high-income countries. Lancet 2011; 377:1162–74.

II. WHO. Adolescent friendly health services: an agenda for change. Geneva, 2002.

III. UNICEF. UNICEF state of the world’s children 2011—adolescence: an age of opportunity. 2011.

IV. Kennedy I. Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs. 2010.

V. Lee L, Upadhya KK, Matson PA, Adger H, Trent ME. The status of adolescent medicine: building a global adolescent workforce. Int J Adolesc Med Health. 2016 Aug 1;28(3):233-43. doi: 10.1515/ijamh-2016-5003.

VI. Fonseca H. Compreender os Adolescentes - Um Desafio para Pais e Educadores. P ed. Lisboa: Editorial Presença, 2002.

VII. João B. Pereira, Helena Fonseca, Teresa Nunes, Cristina Trindade - Evolução do Internamento de Adolescentes no Serviço de Pediatria do Hospital de Santa Maria. Acta Pediatrica Acta Pediam Port., 2003; N° 5; Vol. 34: 353-357

VIII. Lam PY, Yeo M, Sawyer SM. Adolescent admissions to a tertiary paediatric hospital: a dynamic pattern. Ann Acad Med Singapore. 2003 Jan;32(1):58-63.

IX. Payne D, Kennedy A, Kretzer V, Turner E, Shannon P, Viner R. Developing and running an adolescent inpatient ward. Arch Dis Child Educ Pract Ed. 2012 Apr;97(2):42-7. doi: 10.1136/archdischild-2011-300068. Epub 2011 Sep 21.

X. Hergenroeder AC, Benson PA, Britto MT, Catallozzi M, D'Angelo LJ, Edman JC, Emans SJ, Kish EC, Pasternak RH, Slap GB. Adolescent medicine: workforce trends and recommendations. Arch Pediatr Adolesc Med. 2010 Dec;164(12):1086-90. doi: 10.1001/archpediatrics.2010.211.

XI. Emans SJ, Austin SB, Goodman E, Orr DP, Freeman R, Stoff D, Litt IF, Schuster MA, Haggerty R, Granger R, Irwin CE Jr; participants of the W.T. Grant Foundation conference on Training Physician Scientists. Improving adolescent and young adult health - training the next generation of physician scientists in transdisciplinary research. J Adolesc Health. 2010 Feb;46(2):100-9. doi: 10.1016/j.jadohealth.2009.10.004.

XII. Dougal S Hargreaves, Russell M Viner - Adolescent inpatient activity 1999–2010: analysis of

English Hospital Episode Statistics data. Arch Dis Child. 2014 Sep; 99(9): 830–833.

Not Always or Never – the Importance of a Careful Evaluation!

Sara Pires da Silva; Cláudia Gonçalves; Maria Manuel Lopes; Maria José Costa

Abstract

Introduction: Pediatricians are in a unique position in child abuse (CA) approach. CA diagnosis requires a high degree of suspicion and represents a medical and ethical challenge.

Case Report: Eighteen-month-old boy, with prematurity history, institutionalized, brought to pediatric emergency care presenting hard edema of the right thigh. In the previous day, he had been vaccinated and trauma was discarded. At the clinical examination, he was in good health condition, without fever.

In the right thigh, he presented a hard-painful edema and was adopting an antalgic position with partial march refusal. He had no apparent signs of trauma and had a good relationship with the caregiver. The x-ray showed a right femoral diaphysis fracture. He was hospitalized for fracture correction and the multidisciplinary child abuse team and the institution direction was informed of the situation. Subsequently, in the surveillance cameras images, was visualized a moderate impact fall, which could justify this fracture. In these images, the child is shown to be comforted by the institution professionals. Currently he is at the institution care, with regular pediatric consultations, without any incidents.

Discussion: This case alerts us to the suspicion of CA in the presence of unjustified fractures. It reminds the importance of a correct orientation to the competent entities, avoiding to erroneously label situations of accidental trauma like CA. A structured and prejudice free evaluation is essential for correct clarification. It is urgent to implement more medical training in this area, thus increasing pediatricians’ diagnostic acuity of these risky situations in pediatric emergency care.

Keywords: child abuse, fracture, multidisciplinary child abuse team

Abbreviations: CA – Child abuse

Introduction

Child abuse accompanies the history of mankind, however, the problem of physical maltreatment of children has emerged in the international medical lexicon only in the last 55 years. It is in 1962, after the definition of child abuse syndrome, that the medical community directs its attention in a sustained way to the infantile physical maltreatment. (1)

In parallel with this growing medical concern, society at large embraced a more responsible and supportive role in the well-being and safety of children. Fundamental rights such as the physical and emotional integrity of children are today widely recognized by the community. (2)

In Portugal, it is after the 1980s, through various institutions such as the Child Support Institute, the Center for Judicial Studies and the Social Pediatrics Section of the Portuguese Pediatric Association that particular attention is given to this problem. The Child Protection Commissions were created only in 1991, and in 1992 hospital children support centers and young people at risk (NHACJR) with a multidisciplinary medical-socio-legal approach were created. (3) The guiding principles for intervention of these committees have been legislated since 1999. Law 147 establishes, in its 4th article, that the intervention of these entities should give priority to children’s and adolescent’s rights and interests respecting their privacy, right to image and reservation of their personal life. This approach should occur as soon as the situation of danger is known and by the sole action of these entities whose action is indispensable. It also determines that parental responsibility should be a prerogative and that parents/guardians as well as children and adolescents should be informed of their rights, the reasons for intervention and processing. (4) Currently, child abuse can be encompassed in different legal aspects, and physical maltreatment against minors constitutes a public crime, under article 152-A of the Portuguese Penal Code. (5)

Despite this collective effort of the civil and medical society, cases of child abuse continue to arise and it is within this framework that the Pediatrician is in a unique position to its approach. Its diagnosis requires a high degree of suspicion, representing a great medical and ethical challenge.

Case report

Eighteen-month-old boy, 30 weeks premature, institutionalized since birth. He was brought to pediatric emergency care presenting hard edema of the right thigh. The caregivers denied fever or witnessed trauma, referring a vaccine inoculation in the referred thigh in the previous day.

At the clinical examination, he was in good general condition, with hard-painful edema of the right thigh and was adopting an antalgic position with partial march refusal. No other changes were observed, namely apparent signs of trauma. He apparently had a good relationship with the caretaker who accompanied him.

The right lower limb radiography showed a right femoral diaphysis fracture, with no apparent bone density change. Caregivers, after this diagnosis showdown, continued to deny any history of witnessed significant fall or trauma. He was hospitalized for fracture correction. During hospitalization, NHACJR and the board of the institution where the child lives were informed. As a part of the investigation, from the obtained surveillance cameras images, it was visualized a moderate impact fall from own height. This happened in the day prior to medical observation and could justify the fracture found. In the same images, the child is shown to be comforted by the institution professionals.

The blood tests did not shown any change of the phosphocalcic metabolism. Currently with 23 months old, the child is in the care of the same institution, with regular pediatric consultations and without any new occurrence.

Discussion

The prevalence of child abuse is difficult to assess and national data is lacking. In 2003, UNICEF reports that about 3,500 children under 15 years-old die each year as a result of maltreatment in developed countries. This report outlines a comparative picture of physical abuse in children in the 27 richest countries in the world and refers to Portugal as presenting rates 10 to 15 times higher than the countries at the top of the list. (6)

The most common child physical abuse injuries are bruises followed by fractures. (7) Although fractures are a frequent sign of maltreatment, it is difficult for physicians to differentiate those caused by maltreatment from those resulting of accidental injury. (8) Studies indicate that, in children under 3 years-old, approximately 20% of fractures caused by maltreatment are not diagnosed in the first assessment and are labeled as accidental injury or other etiology. (7,8) This inaccurate differentiation could be responsible for serious consequences. It is known that in case of child abuse, aggression will be repeated in 35% of cases and 5% to 10% of patients will die if there is no intervention. (8)

Trauma injuries, including fractures, are frequent in childhood and the great majority are accidental. However, physicians that deal with children should be alert to the fact that any fracture may be caused by child physical abuse. (7,10) In order to increase the diagnostic accuracy of this form of maltreatment, the pediatrician should take into account the clinical history of the caregivers, the child’s age, the location and type of fracture and its mechanisms, as well as the presence of other lesions that may corroborate or invalidate the diagnosis. (7,9,10)

As with other forms of child abuse, the version of the events passed on by the different caregivers may be contradictory or often disproportionate to the observed trauma. Some warning signs, can be injuries inconsistent with the child's motor acquisitions, injuries attributed by caregivers to animals or other children, and the delay in health care admission. (7,9,10) In children with multiple caregivers, as in the present case, ascertaining the timing and cause of the trauma can be difficult and unenlightened, without however being synonymous of physical abuse.

Approximately 80% of fractures caused by maltreatment occur in children less than 18 months-old. After gait acquisition the traumatic etiology gains preponderance, mainly in relation to fractures of long bones like the femur and the humerus. (7,10) In this manner, it is understood that age is the most important risk factor for inflicted bone damage. (10)

Although there are no pathognomonic bone lesions of abuse, some characteristics are more suggestive of it. Rib fractures, especially if postero-medial, and metaphyseal fractures of long bones present high specificity for physical abuse, especially if they occur in infants. Although rare, fractures of the scapula, spinous process and sternum are also specific. (7,10) Multiple fractures, particularly if at different resolution stages, present high specificity. (10) In contrast, being non-specific, diaphyseal fracture of long bones is the most commonly identified fracture pattern in maltreated children. (7) There should be a high degree of suspicion if other skin lesions such as bruises, burns and scars, of unusual location such as the perineum, palms of the hands and soles of the feet, retro-auricular region and oral cavity, or if the injuries present a characteristic shape of objects. (7,9,10)

Nevertheless, as in the case presented, some fractures of long bones may be due to common accidental causes such as falls from one's own height. Several studies have shown that a small fall with knee support may be responsible for a fracture of the distal femoral metaphysis, and there are also cases of femoral diaphyseal fractures in children who fall from their height along running. (7, 11)

The impact and the medical, social, familiar and legal implications associated with the alleged child abuse, require not only a high degree of clinical suspicion for its diagnosis but also a high sensitivity and experience for an adequate evaluation, free of prejudices, to clarify the most dubious situations. It is up to the Pediatrician to consider this diagnosis with common sense and parsimony in the evaluation of children with fractures or other physical injuries of unknown etiology and their referral to the NHACJR as a multidisciplinary team plays a crucial role in clarifying these situations and protecting the child.

Conclusions

The present case alerts to the importance of, in the face of any fracture, even if it is commonly accidental, the pediatrician should consider the possibility of maltreatment in his differential diagnoses. It also recalls that apparently unjustified physical injuries should be investigated in this context.

On the other hand, it also reminds us of the importance of referring these cases of suspected abuse to competent entities such as the NHACJR, in order to avoid labeling incidents of accidental trauma as maltreatment and to ensure an adequate follow-up of these children.

Additionally, it emphasizes the need for a well-structured and unbiased research so that a correct differential diagnosis can be made between fractures due to physical abuse and other situations, pathological or accidental.

It is imperative to implement more medical training in this area of ​​knowledge, thus increasing the diagnostic acuity of these risk situations in urgent care by pediatricians.

References

Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA.1962;181:17–24

Equipa Técnica de Apoio à Comissão Nacional de Proteção de Crianças e​
Jovens em Risco, Guia de orientações de promoção e proteção dos direitos das crianças. Junho 2006. Acessível em http://www.cnpcjr.pt

Paula Nunes et al, Maus-tratos infantis – a realidade de um Hospital Distrital! Acta Med Port. 2010; 23(3):413-418

Código Penal Português, Art 152º - A.

Lei n.º 147/99 de 1 de Setembro, com as alterações impostas pela Lei n.º 31/2003 de 22 de Agosto

Centro de Investigação Innocenti, Lançamento do Relatório “Report Card 5” do Centro Innocenti, UNICEF, 2003. Acessível em: https://www.unicef.pt/docs/pdf_arquivo/2003/03-09-18_report_card_5.pdf

Emalee G. Flaherty, et al. Evaluating Children With Fractures for Child Physical Abuse, Pediatrics, Volume 133, Number 2, February 2014

Ravichandiran N, et al. Delayed identification of pediatric abuse related fractures. Pediatrics. 2010;125(1):60–66

Cindy W. Christian, et al. The Evaluation of Suspected Child Physical Abuse, Pediatrics. Volume 135, number 5, May 2015

Jill C. Glick, et al. Physical Abuse of Children, Pediatrics. Volume 37, number 4, April 2016

Pierce MC, Bertocci GE, Janosky JE, et al. Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics. 2005;115(6):1712–1722

Figure 1: X-ray of right leg with femoral fracture

Voluntary Intoxication in Adolescents - 2 Years Experience in the Pediatric Emergency Service of a III Level Hospital

Vanessa Gorito,

Marta Rosário, Marta Pinheiro, Cristina Ferreras,

Mayara Nogueira, Sofia Vaz, Ana Maia,

Luís Almeida Santos

Pediaric Medical Services/ Peidatric Emergency Services - Integrated Pediatric Hospital, São João Hospital Center, Porto, Portugal

Abstract

Introduction: Voluntary intoxications (VI) by alcohol (Alcohol Intoxication - AI), medicines (Pharmacological Intoxication - PI) or other psychoactive substances (PAI) are a worrying and potentially fatal reality, in the Pediatric Emergency Service (PES).

Objectives: Characterization of the adolescents between 10 and 17 years and 364 days of age admitted for VI in the Pediatric Emergency Service of Oporto.

Methodology: Retrospective descriptive study of cases of VI admitted between July 1, 2014 and June 30, 2016, coded as acute intoxication according to the ICD9, considering socio-demographic variables, description and orientation of the episode.

Results: 244 episodes of VI were recorded in this period, 55.3% female; 81% between 15 and 17 years. There were 141 episodes of AI (57.7%) and 76 episodes of PI (31.1%) - of these, 40.7% due to ingestion of psychoactive medicines. Usually, AI corresponded to sporadic cases of excessive consumption. PAI occurred in ~ 10% of adolescents (n=25). In 52% of these cases, concomitant consumption of alcohol existed (n=12). About 25% of all adolescents (n=62) identified underlying psycho-behavioral disorders. Urgency evaluation was recommended for Pedopsychiatry in 80% of Pharmacology Intoxication’s (n = 61). Of the 244 episodes, 4% of the patients were hospitalized; 3 dropouts of the PES and one died.

Conclusions: VI are associated with high consumption of human and economic resources. AI usually result from acute and isolated consumption. PI are often associated with psycho-behavioral disorders. This study alerts us to the importance of characterizing and accompanying these adolescents.

Introduction

The extension of the pediatric age to 18 years is associated with the emergence of new realities and needs in this age group, because adolescence is a period of physical maturation, acquisition of cognitive, behavioral and emotional skills, being characterized also by the search for new experiences. (1) Experimentation is in many cases the starting point for abuse and intoxication. Voluntary intoxication has been defined by WHO as the act in which an individual deliberately ingests an excess substance. (2)

This type of acts has been an increasing reality in pediatrics, especially among adolescents, representing a form of internal conflict resolution, depressive and anxiety symptoms that accompany the physical, psychic and social reorganization of adolescence (3). It can be difficult to determine whether the intent of the intake is self-destructive or just a wake-up call. Factors such as alcohol and drug use, difficulty in interpersonal relationships, eating disorders, low self-esteem, exposure to violence, and depressive feelings, among others, seem to increase the risk of voluntary medicines intake. (4)

In the case of PI, the medication often used is at home and belongs to the patient or to cohabitants, with psychotropic drugs being the most used class. The number of cases in female gender is generally higher, although mortality is higher in the male. Adolescent medicines intake with suicidal intent may represent a risk factor for mental problems and suicide in adulthood. (3)

Alcohol is the most frequently implicated substance in acute intoxications, although, under current law in Portugal, it´s use is forbidden in youngers than 16 years of age. AI is in the majority of cases a single and accidental episode. (1) The consumption of psychotropic substances is an increasing practice, with Cannabis being the most popular consumed in this population. (6) According to the available data, both AI and PAI have an increasing tendency and are associated with cases of intoxication at an earlier age. (1)​
Voluntary intoxication in adolescents is similar to those in adults. The significance of the event may vary by age, but the risk assessment in emergency units is usually identical. Medical doctors must interpretate these situations as medical emergencies. There is a tendency to underestimate the importance of voluntary poisoning in adolescent, because usually it is not fatal. (7)

This public health problem is a potentially fatal reality in the Pediatric Emergency Service (PES). Intoxications are conditioned by multiple factors, namely, age and psycho-social context, and may constitute the beginning of a pattern of consumption, a wake-up call or suicide attempt, thus compromising the bio-psycho-social development of these adolescents, for which it is particularly relevant to be the object of study.

Objectives

In this study we propose to characterize the adolescents between 10 and 17 years and 364 days of age admitted to the Pediatric Emergency Service of Oporto with VI, considering the demographic variables, social context, suicidal ideation, existence of similar episodes, pathological antecedents, habitual medication, complementary diagnostic, therapeutic and post-treatment counselling.

Methodology

A retrospective study was carried out in the field of descriptive statistics, where all individuals, aged between 10 years and 17 years and 364 days were included, who were admitted to the Porto Pediatric Emergency Room with a diagnosis of VI in the period between July 1, 2014 and June 30, 2016, coded as acute intoxications, according to the ICD9.

It was decided to characterize this population regarding the following variables: demographic, social context, suicidal ideation, existence of similar episodes, pathological antecedents, regular medication, complementary means of diagnosis, therapeutics performed and orientation after episode.

Data analysis and statistical treatment were performed using the software -Statistical Package for the Social Sciences (SPSS, version 19) as well as Microsoft Excel.

Results

There were 244 emergency episodes diagnosed as VI during the indicated period. Regarding the distribution by type of intoxication, there were 141 cases of AI, 76 cases of PI and 25 cases of PAI.

Of these, 55.3% were of the female gender (Graphic 1). Regarding the gender distribution of VI, we found 64 cases of PI in girls and 83 cases of AI in boys (Table 1).The majority of adolescents were aged between 15 and 17 years (81%) with a minimum age of 11 years. The median was 16 years (P25 = 15 years; P75 = 17 years). According to the distribution by age, combined intoxication occurred more frequently among older adolescents. PI and AI occurred among all ages, being more predominant since 15 years (Table 2).

Graphic 1 – Distribution by gender

Table 1: Distribution of Intoxication type by gender

Table 2: Distribution of Intoxication type by age

The AI corresponded to sporadic cases of excessive consumption, with no new admission to the PES for the same reason. In about 74% of the cases the blood alcohol content was determined and intravenous fluid therapy was performed in 69%. In one case there was also a cumulative intake of medicines, with suicidal ideation and subsequent orientation to Pedopsychiatry.

Approximately 10% of the adolescents (n = 25) were admitted to the PES, confirmed by positive urine tests for Cannabinoids. In 52% of these cases, concomitant alcohol consumption (n = 12) occurred, usually in a social context, with friends.

Concerning PI, 40.7% occurred due to ingestion of psychoactive drugs (benzodiazepines, antipsychotics and antidepressants). Other drugs involved were, analgesics, anti-inflammatories, antihistamines and antibiotics. Most drugs were usually from themselves or from caregivers.

Graphic 2 – Distribution by Intoxication type

About 25% of the total number of adolescents admitted for VI (n = 62) identified basic psycho-behavioral disorders; 44 of these had a follow-up by Pedopsychiatry and 38 were medicated with psychotropic drugs.

In 19 episodes of FI, gastric lavage was performed and administered activated charcoal. Urgency evaluation was recommended for Pedopsychiatry in 80% of FI´s (n = 61).

Of the 244 episodes, 4% of the patients were hospitalized; 3 patients left the PES and one of PI committed suicide about 3 weeks after discharge (by strangulation). The remainder were asymptomatic.

Discussion

VI are associated with high consumption of human and economic resources, constituting a threat to the physical and psychological well-being of the adolescent and should be prevented. According to the literature female gender is a risk factor because girls consider suicide more frequently during adolescence. (7) (8) PI are more common in girls (9). Instead, the use of drug and alcohol intoxication was found especially in boys.

Although the recent data refers consumptions at an earlier age, in our study the vast majority of adolescents were aged between 16 and 18 years.

More than half of the episodes were due to acute alcohol intoxications. As described by other authors, AI´s generally result from acute and isolated intakes, with no need for new resort to PES for the same reason. (6)

According to the available literature no significant difference between genders was found in the incidence of total intoxication. In some studies the female gender had higher incidence rates. In our study, a slightly predominance of girls was observed.

In relation to PI, also according to the literature, they are often associated with basic or new psycho-behavioral disorders, requiring follow-up. The authors consider it is important to highlight that 13 cases of PIs occurred due to intentional overdosing of the psychoactive drugs with which they were medicated, that further points out the need to adequately follow these youngsters. This data is overlapping with other published studies (6).

Regarding to intoxication by other psychoactive substances, Cannabis was the main drug, as described in the literature. (1) Consumption combined with alcohol in more than half of adolescents, warns us to behavioral problems and reinforces the existence of standard behaviors in a group context, which requires urgent behavioral intervention. Some authors argued that it is hard to distinguish between suicide attempt adolescents and at-risk adolescents, suicide attempts being “one point on a continuum of adolescent problem behaviors.” (10) Physiological counseling and personal approach in accompanying patients to overcome suicidal ideation should be a priority to the healthcare providers.

It is also important to reinforce that, of the 3 adolescents who declared suicidal ideation, one of them consummated the act later, showing that acute intoxications in this age group are potentially very serious. Therefore, this study alerts us to the importance of characterizing and accompanying these adolescents. The Health Services should develop preventive approaches and strategies and / or early intervention in this population.

References

Ximena Sanchez-Samper, John R. Knight - Drug Abuse by Adolescents- Pediatrics in Review. 2009

Kapur N, Cooper J, Hiroeh U, et al. Emergency department management and outcome for self-poisoning: a cohort study. Gen Hosp Psychiatry 2004;26:36–41

Portzky G, van Heeringen K. Deliberate self-harm in adolescents. Curr Opin Psychiatry. 2007;20(4):337-42.

Ghazinour M, Emami H, Richter J, Abdollahi M ,Pazhumand A.. Age and gender differences in the use of various poisoning methods for deliberate parasuicide cases admitted to loghman hospital in Tehran (2000-2004).Suicide Life Threat Behav. 2009;39(2):231-9.

Neto C, Fraga S, Ramos E. Consumo de substâncias ilícitas por adolescentes portugueses. Ver Saúde Pública 2012; 46:808-815

Bailey B. Baud F, Hanton P, Thabet H, editors. Particularites des intoxications chez l,enfant. Intoxications Aigue. Paris: Springer-Verlag; 2013. 357–70.

Lewinsohn PM, Rohde P, Seeley JR, et al. Gender differences in suicide attempts from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2001;40:427–34. 

[10] Hawton K, Witt KG, Taylor Salisbury TL, et al. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2015;12:CD012013. 

[11] Cheng TL, Wright JL, Pearson-Fields AS, et al. The spectrum of intoxication and poisonings among adolescents: surveillance in an urban population. Inj Prev 2006;12:129–32. 

Schonberg SK. Can adolescent suicide attempters be distinguished from at-risk adolescents? Pediatrics1991;88:636–7. 

Chapter 6

Psychology

Attempts Suicide in Childhood: an In(visible) Phenomenon

Ana Paula Antero Lôbo

Master in Collective Health - University of Fortaleza/UNIFOR

Ana Paula Vasconcellos Abdon, Adriana Rolim Campos Barros

Professor in Post-Graduate Program in Collective Health - University of Fortaleza/UNIFOR

Igho Leonardo do Nascimento Carvalho

PhD Student in Collective Health - University of Fortaleza/UNIFOR

Abstract

This study investigated the characteristics of drug poisoning suicide attempts in children (0-9 years). Retrospective, documental, with quantitative approach, was carried out at the Toxicological Assistance Center of Fortaleza/Ceará/Brazil. The notification sheets, resulting from attendance in the period from 2010 to 2014, were collected in June/August 2015. The analysis consisted of the simple and relative frequencies of sociodemographic, occupational and intoxication characteristics. Three cases (0.3% of the notifications) were registered, all of them male. Studies indicate a male predominance in cases of domestic accidents in this age group. However, it is emphasized that children manifest a desire for death, often being interpreted as a "child's thing" or mistaken for a domestic accident. In the research, the mean age was 7.0 ± 1.0 years, being within a spectrum where the concept of death may be more developed. Two cases were students, with a record of child labor. The school, therefore, plays an important role in the overall development of the infant, although studies highlight a high number of children with school complaints and the occurrence of bullying, considered a global public health problem. The pharmacological classes used were "anxiolytics and hypnotics", "antidepressants" and "antipsychotics", with predominance of the liquid form. More in-depth studies on the subject are needed, in addition to guidance on toxic agent packaging and household surveillance. The training of health professionals and education is also important for the prevention of this phenomenon, although incipient in its data or underreported.

Suicide is a complex phenomenon, considered a serious public health problem. Rates of childhood suicide, however, are low, due to the concept of death still in development in this period. Attempts of suicide can be manifestations of suffering at this stage. This study investigated the characteristics of drug poisoning suicide attempts in children (0 – 9 years). Retrospective, documentary, was performed at the Center for Toxicological Assistance of Fortaleza/Ceará/Brazil. The notification sheets, resulting from attendance (2010 – 2014), were collected in June/August 2015. The analysis consisted of the simple and relative frequencies of sociodemographic, occupational and intoxication characteristics. Three cases (0.3% of the notifications) were recorded, all of them male. Studies point to male predominance in cases of domestic accidents, although they emphasize that children's desire for death is often interpreted as a "child's thing" or mistaken for an accident. In the research, the mean age was 7.0 ± 1.0 years, where the concept of death may be more developed. Two cases were students, with a record of child labor, demonstrating, therefore, that the school plays an important role in the development of the infant. The pharmacological classes used were "anxiolytics and hypnotics", "antidepressants" and "antipsychotics", with predominance of the liquid form. More in-depth studies on the subject are needed, in addition to guidance on toxic agent packaging and household surveillance. Training of health professionals and education is important for the prevention of this phenomenon, although incipient in its data or underreported.

Keywords: Attempted suicide; Child; Poisoning; Medicines

Introduction

Suicide, a complex and multicausal phenomenon, characterized as self-inflicted violence with intent to die (WHO, 2002), is considered a serious public health problem (WHO, 2014). According to the World Health Organization (WHO), suicide rates between the ages of 5 and 14 are 1.5/100,000 in boys and 0.4 in girls (WHO, 2000). Other studies estimate an average rate of 0.6/100.000 inhabitants, with a ratio of 2:1, between men and women, in this age group (Dilillo et al., 2015). Research conducted in Brazil between 2000 and 2012 recorded 61 deaths due to suicide in children under 10 years of age during this period (Machado & Santos, 2015).

Despite the low rates of this phenomenon in the infant age group, which may be associated with the level of development on the concept of death (Kuczynski, 2014), WHO (2006) warns of one of the great myths in the world that is the fact that children do not commit suicide.

The representation of childhood is built in societies from a cultural, historical, political and social process, reflecting, consequently, changes of attitudes towards it throughout history (Moura, Viana, & Loyola, 2013). The boundaries between being a child and being an adult have always been the subject of theorizing, showing ambiguity in the Brazilian contemporaneity in the face of phenomena such as the increase in child crime, the stay of adults in their parents' houses, the discussion on reducing the childhood as a consumer market, among others (Silveira Netto, Brei, & Flores-Pereira, 2010).

The children, therefore, have undergone a process of "adultization" through various social, emotional, cultural, economic phenomena (Silveira Netto et al., 2010), causing transformations in the expression of suffering and, consequently, in their care. An example of this is the change in the profile of infant morbidity and mortality, which in Brazil was directed toward diseases such as diarrhea, verminosis, respiratory diseases and other infections. Currently, the growing prevalence of chronic diseases, such as obesity (Gomes, Pinto, & Gomes, 2012; Costa, Souza, & Oliveira, 2012) and depression, have important repercussions on child development (Calderaro & Carvalho, 2005).

Child suicide, a subject that has not yet been approached, corroborates this process of "adultization" and demonstrates that children can also present existential suffering and are afflicted by life's difficulties (Angerami-Camon, 2002).

This study, therefore, aimed to investigate the characteristics of suicide attempts by drug intoxication in children, understanding that it is important to give visibility and reflect on this phenomenon, even if initially incipient in its data or underreported.

Methods

This is a retrospective, documental, quantitative, descriptive-exploratory study (Creswell, 2007; Medronho, Bloch, Luiz, & Werneck, 2011). It comes from the research project entitled "Study of poisoning by drugs registered by the Center for Poisoning of Ceará State."

Data were collected from June to August 2015 at the Center for Toxicological Assistance (CEATOX), a reference service in the treatment of intoxication, located in Fortaleza, Ceará State. The study population consisted of the notification forms, resulting from face-to-face consultations at CEATOX in the period from 2010 to 2014, whose circumstances referred to the suicide attempt for drug intoxication, totaling 926 cases, which represented 68.0% of the notifications for this period. Three cases of suicide attempt were registered in children aged 0 - 9 years, object of study of this work, corresponding to 0.3% of the notifications (the age range considered is based on the criteria adopted by WHO) (WHO, 1986).

Data collected was based on the transcription of the notification form whose data were stored and analyzed in the statistical package SPSS® 22.0. The simple and relative frequencies of socioeconomic, demographic and intoxication characteristics were obtained, including the identification of pharmacological classes and toxic agents.

The legal aspects and ethical principles in research involving human beings were met, according to Resolution 466/12 and favorable opinion of the Research Ethics Committee (CEP / IJF), protocol no. 1,060,172 (CAAE: 43543215.4.0000.5047).

Results

All the children that attacked their own lives were males (n = 3), with a mean age of 7.0 ± 1.0 years. The episodes occurred in the years of 2012 (n = 2) and 2014 (n = 1) and in the months of May (n = 2) and October (n = 1). Two of them (n = 2) lived in the city of Fortaleza, while only one (n = 1), in the interior of the Ceará State. In relation to the occupation, two (n = 2) students were identified, and one (n = 1) work as a professional in the sciences and arts (craftsman) (Table 1).

Table 1: Sociodemographic and occupational profile of suicide attempts by drugs according to the age range of children. Ceará/Brazil (2010-2014).

Source: Poison Control Center (CEATOX/CE)

In all cases (n = 3), the intoxication occurred in the same municipality of residence and oral intake of the drug was given. The places of accomplishment of the intent were the residence (n = 2) and the work (n = 1), in the case of the craftsman (Table 2).

There was a "single acute" type of poisoning in the three cases reported (n = 3), in two of them (n = 2), in liquid form and one (n = 1) in tablet form. In all occurrences (n = 3), only one toxic agent was involved in each trial. Hospital admission was required in two reports (n = 2) (Table 2).

The degree of poisoning varied, with mild (n = 1), moderate (n = 1) and severe (n = 1) poisoning. The hospital discharge was the clinical outcome in two reports (n = 2), with one patient record (n = 1) "not found". All (n = 3) remained in the hospital for up to 24 h (0 - 1 day) (Table 2).

The pharmacological classes identified in the suicide attempts in this age group were "anxiolytics and hypnotics" (n = 1), "antidepressants" (n = 1) and "antipsychotics" (n = 1). The agents causing the poisoning corresponded to Diazepam (n = 1); Periciazine (n = 1) and, in one case (n = 1), this data was not reported.

Table 2: Characteristics of intoxication of suicide attempts by drugs according to the age range of children. Ceará/Brazil (2010-2014).

* Patient not found after hospital admission.

Source: Poison Control Center (CEATOX/CE)

Discussion

This study is characterized as a contribution to a greater visibility of the phenomenon of suicide/suicide attempt in children, due to the small productions on the subject and the transformations for which childhood is subject in the contemporary world.

In the present study, the three cases of suicide attempt due to drug intoxication were male. These data find reverberation in surveys conducted in Uruguay (Pandolfo et al., 2011) and Argentina (Bella, Fernández, & Willington, 2010), which identified a male prevalence in the occurrence of this event among children under 10 years of age. A survey conducted in the Brazilian city of Maringá (PR/Brazil), based on data from an Intoxication Center (2006 - 2009), also presented three cases of suicide attempts in children, two of whom were male, but did not deepen their analysis (Rosa Et al., 2015).

A retrospective study conducted in France with children under 13 years of age also highlighted the male predominance in the lower age group and using more violent methods (Berthod, Giraud, Gransel, Fourneret, & Desombre, 2013). In Colombia, the data are equivalent for both men and women, and point to the variability of the characteristics of suicide attempts in this age group (Vásquez-Rojas & Quijano-Serrano, 2013).

Scientific literature emphasizes that in the children's age group there is a male predominance in cases of domestic accidents. This fact is understood, culturally, from the notion that boys acquire independence from parental supervision to perform their activities earlier than girls and are therefore exposed for a longer time to situations that precede accidents (Filócomo, Harada, Silva, & Pedreira, 2002).

However, according to Angerami-Camon (2002), although the means for suicide attempts are not as effective as those used by other age groups, children manifest a desire for death, which is often interpreted as a "child's thing" or confused with domestic accident. For example, a survey of infants hospitalized for domestic accidents in the city of Recife (PE/Brazil) concluded that the accidental act contained many characteristics associated with a suicidal tendency, especially those related to family conflicts (Santos & Melo, 2016). Thus, the questioning about underreporting or inadequate records of these cases is raised, rethinking important sociocultural aspects involving, mainly, issues of gender, childhood and death.

The domestic accident is the main circumstance of exogenous intoxication in children, with greater vulnerability among children under five due to the characteristics of this phase of development, such as curiosity and world exploration (Vilaça & Cardoso, 2014). However, drug intoxication increases significantly with age (Werneck & Hasselmann, 2009). In the present study, this average was 7 ± 1.0 years. It is therefore presented within a spectrum where the concept of death may be more developed and the suicide attempt may be the manifestation of a pain/suffering that one wishes to eliminate, without necessarily being conscious of the concept of death (Angerami-Camon, 2002).

Even if the definition of suicide is attributed to the intentionality of dying, this correlation can be complex (WHO, 2002). Some studies claim that half of the accidents involving children are masked attempts at suicide. In spite of this, this phenomenon has been gradually displacing the myth of childish innocence and alerting parents, education and health professionals to this care (Fensterseifer & Werlang, 2003).

Regarding the occupation, two cases of students were identified in the present study, with a record of child labor. In this age group, the school plays an important role in the overall development of the infant. However, there are now a large number of children with school complaints referred to health professionals. Among the main learning difficulties perceived by teachers, problems in writing, reading, inattention and behavior change are the most difficult to deal with by teachers (Frederico Neto et al., 2015).

The learning process involves several factors, often reflecting the social dynamics in which it is embedded. School complaints, on the other hand, also need to be approached in an expanded way, considering their historical, socio-cultural, institutional and political-economic dimensions (Dazzani, Cunha, Luttigards, Zucoloto, & Santos, 2014). At the individual level, school failures seem to be related to feelings of failure and self-deprecating self-image (Jacob, Loureiro, Marturano, Linhares, & Machado, 1999).

The school can be a promoter of health, but also of conflicts. Bullying among children is considered a major public health problem worldwide. Characterized as a repeated and intentional aggression, this phenomenon can generate in the victim negative consequences in the short and long term, such as depression, anxiety, low self-esteem, delinquency and suicide (Shetgiri, 2013, Kuczynski, 2014).

A study conducted in the city of Canada, for example, suggests early intervention strategies, still in elementary school, due to the presence of suicidal ideation associated with verbal or electronic bullying among children. More depressed or anxious students with low self-esteem and impoverished family relationships are also more vulnerable to this association (Feng, Waldner, Cushon, Davy, & Neudorf, 2016).

In relation to child labor in Brazil, the insertion of the age group of 5 to 13 years in economic activities is prohibited by law. The work of children and adolescents is associated with complex effects, such as low schooling indicators; Exposure to risk situations; Early maturation and loss of play capacity, essential for the development of affectivity (Martins, Bassitt, Wanderley, & Silva, 2013).

Play represents for the child a creative experience in which it can move from a mere spectator to a transforming agent. It is through the play that it expresses itself and interferes in a world that is meaningful to it and that can not be fully translated into words. It has, therefore, a function of extreme importance in the health and the emotional development of the subject, favoring the relations with himself and with the world (Sekkel, 2016).

In addition, when this play is interrupted or crossed by negative experiences can generate important effects throughout life. Adherence, such as sexual and physical abuse, as well as parental domestic violence, are associated with the subsequent prevalence of mental disorders, suicidal ideation, and suicide attempts (Fuller-Thomson, Baird, Dhrodia, & Brennensthul, 2016).

Suicide may be associated in childhood also with mood disorders, eating disorders, psychoses and behavioral disorders, as well as family maladjustments and chronic physical illnesses (Scivoletto et al., 2010). In the case of toxic agents, a study shows a predominance of the use of psychotropic drugs in suicide attempts, followed by analgesics and drugs for attention-deficit hyperactivity disorder in this age group (Sheikh, Hendry, Lynch, Kalynych, & Kraemer, 2015).

The pharmacological classes involved in the suicide attempts in the present study were "anxiolytics and hypnotics", "antidepressants" and "antipsychotics", corresponding in some way to the psychiatric disorders highlighted in the literature, as well as to the toxic agents used in those attempts. In the present study, the use of the drugs in liquid form is favored, favoring their ingestion in this age range.

Toxic agents involved in intentional or accidental infant poisoning are commonly found in the home environment. Most occurrences are favored by inadequate vigilance of those responsible, ease of access to agents, as well as educational, economic and social factors of families (Vilaça & Cardoso, 2014).

Child poisoning, especially in children under 6 years of age, is potentially preventable in most cases. In accidental poisonings, for example, the use of "analgesics and antipyretics", which are over-the-counter drugs, is predominant. These data raise the need for reforms in health and industrial policies in order to raise awareness of toxic potential, appropriate storage and general precautions to promote safety in the home environment (Ozdemir, Bayrakci, Teksam, Yalcin, & Kale, 2012; Mutlu, Cansu, Karakas, Kalyoncu, & Erduran, 2010).

Vilaça and Cardoso (2014) also highlight some important measures to prevent intoxications in this age group: store potentially toxic products in original containers, with adequate lids and preferably open to children and far from reach; Never refer to a medicine as sweet and avoid leaving out jars with colored liquids.

The characteristics of intoxications in the present study (acute single poisoning, hospital discharge as the main outcome and reduced hospital stay) demonstrate the low lethality of suicide attempts using drugs. These data reinforce the idea that children use less effective methods than in other age groups (Angerami-Camon, 2002). Regarding the degree of poisoning, however, there was variation, denoting the need to broaden the research on the subject.

The limitations of this study stand in the small dimension of the sample and the variability of the findings, besides the underreporting of the data, generating the impossibility of making inferences. However, it does not undermine the importance of insisting on making the invisible visible. For this, it is necessary to continue the studies in depth and wider scope, favoring a care and a closer look at the suffering and subjectivity of these children.

Conclusion

Attempts of suicide by drug intoxication in children, recorded in the present study, occurred in males and presented characteristics of low lethality. Despite the small sample size, childhood suicide exists and needs to be seen. More comprehensive studies are needed to better assist and protect this phase of life, as well as the training of health professionals and education to prevent this phenomenon.

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Sleep in Childhood: Perspectives and Social and Cultural Practices

Marco Martins Bento

PIN - Development Center. Faculty of Psychology and Educational Sciences of University of Porto

Mafalda Leitão

Beatriz Ângelo Hospital. Faculty of Psychology and Educational Sciences of University of Porto

Abstract

Sleep is the biopsychosocial process involving the interaction between physiological mechanisms and chronobiological linked to homeostatic dynamics and psychological, economic, social, contextual and cultural factors related to parenting, family beliefs, customs and values underlying the community or culture.

How to sleep, with whom you sleep and where you sleep are some examples of how culture and customs shape sleep habits. Thus, there is the great variability in sleep characteristics, the presence or absence of specific rituals and in determining what is considered a problematic or non-problematic sleep.

Evidence shows that also the characteristics of the child and the parental factors are preponderant in the quality and duration of sleep. The regulation of the sleep-wake cycle depends largely on external factors for that, so early, parenting practices influence the adaptation and the child's behaviour before sleep. There is research shows the negative association between quality of sleep in children and parental beliefs of incompetence and inability to set limits for the sleep. These predict parental practices and maladaptive portion cognitions are to a large extent influenced by culture.

Health professionals should be able to understand the cultural influence on sleep for the families to strategies to improve the adaptation of the child to sleep, respecting norms, social and family customs.

Keywords: sleep, culture, children, parental practices.

 Sociocultural aspects associated with sleep in childhood

Sleep is a biopsychosocial process involving the interaction between physiological mechanisms and chronobiologicals (Giannotti & Cortesi, 2009) and psychological, contextual, economic, social and cultural factors related to parenthood, family beliefs, customs and values underlying a culture or community (Owens, 2004).

Interaction between culture and biology takes a fundamental role in definition of sleep patterns, in the cultural norms and expectations associated with sleep considered normal or problematic (Giannotti & Cortesi, 2009). This interaction is mediated, at a macrossystemic level, for rules and cultural beliefs and societal values; at a microssystemic level, has the influence of parental practices, impregnated with aspects of their culture (Jenni & O'Connor, 2005).

The main sociocultural aspects which negatively affect the child's sleep are: family stress, marital conflicts, poor relations between the child and the environment, reduced parental coping mechanisms, misfits cognitions face sleeping, feelings of parental incompetence, emotional managing difficulties; economic background, family size and space available and demographic aspects (Giannotti & Cortesi, 2009; Simard, Nielsen, Tremblay, Boivin, & Montplaisir, 2008). Among these, misfits’ behaviours and practices on sleeping routines are considered to be the main predictors of sleeping problems in childhood (Mindell & Owens, 2003).

Behaviours and routines associated with sleeping

Parents-child interaction relates to her sleeping, having different rituals/behaviours between cultures regarding sleep. Many documented practices ensure the transition between being awake and asleep: i) physical comfort (e.g., hugging, "Kiss Goodnight", ...); ii) autonomy encouragement (e.g., allowing some crying); iii) movement (e.g., car rides); iv) passive physical comfort (e.g., stay close to the child, without touching her); v) social comfort (e.g., reading a story) (Morrell & Cortina-Borja, 2002). In an investigation, same authors found that a balanced practice between physical active comfort and autonomy encouragement is associated with minor sleep disturbance in childhood.

Concerning to maternal behaviour, Caucasian mothers provide, more frequently, a comfort object to the child (transitional) and tell her a story, compared to African-American and Latino mothers. About 40% of the parents in Portugal remain with the child until she fall asleep (Giannotti & Cortesi, 2009). In contrast, this practice is adopted for about 20% of parents of Nordic countries, Americans and Germans (Valentin, 2005).

Mendes, Fernandes and Garcia (2004), in a Portuguese study, conducted with 100 children from 5 to 10 years, found that 3 percent sleep with a pet and 25% with a transitional object.

The Western industrialized countries feature greater autonomy practices, smaller practices of sharing room with the child, but foster structured sleep routines, such as bathing and massage to the child before bed, as well as, reading stories.

Cosleep and presence of parents to sleep

In certain cultures, as Asia, Africa and America's indigenous, is often sleep in communal spaces, especially sharing bed with their mothers or nuclear family. The cosleeping is more common in Asian countries that Caucasians (Mindell, Sadeh, Kohyama, & How, 2010) and more prevalent in breastfeeding mothers (Rigda, McMillen, & Buckley, 2000). On the other side, in Europe and North America there is a greater tendency to individuality and autonomy, giving a proper space for the child to sleep. The cosleeping varies between 70% in African-American children and 10% in middle-class Caucasian children (Weimer, Dise, Evers, Ortiz, Welldaregay, & Steimann, 2002). Specifically, in the North of Europe, Finland registers less than 10% of cosleeping (Sourander, 2001), opposing to 60% in Sweden, associated with the belief of the importance of shared sleep for the child's development (Welles-Nystrom, 2005). In Portugal, 17% of children sleep in the parents’ bed and slightest cosleeping frequency in parents with higher education (Mendes, Fernandes, & Garcia, 2004).

Giannotti and Cortesi (2009) set as main causes for problematic sleep: the breastfeeding to sleep, sleep in the same room of the parents after 1st year, bottle-feeding overnight, let the child sleeping in parents’ bed and sleep routines. These practices lead to greater sleep problems, such as: increased latency, increased night-time awakenings and reduced total time of sleep.

Differences in the pattern of sleep in childhood

In most industrialized societies, children go to bed later and rise earlier, justified by new technologies and the need of parents to be with their children.

In Asian countries, children lie later, have a lower total time of sleep and there is a greater parental perception of problems associated with sleep (Mindell et al., 2010; 2013). This aspect is associated with greater daytime sleepiness and greater number of naps during the day (Harkness & Super, 1996).

Globalization has allowed us to watch changes in cultural phenomena such as reducing the biphasic sleep (daytime nap), characteristic of Mediterranean, African and South American societies.

In Portugal, on a sample of 2000 children, was found that 97% of two-years-old child take a nap, 68% at the age of three-years-old, 29% at the age of four-years-old and 8% at the age of five-years-old (Silva, Silva, Braga, & Grandson, 2013). 89% of children were asleep a number of hours of night sleep considered suitable (Mendes et al., 2004).

Sleep habits in adolescence

Sleep habits in adolescence characterized into two dimensions: biological and cultural. Biologically, the sleep patterns tend to be late with increasing age; from the cultural point of view, the Asian teenagers lie later than American and European pairs, resulting in less total sleep time and increased daytime sleepiness (Cain & Gradisar, 2010).

Same way, it has been found a relation with the practices associated with falling asleep during childhood: bed sharing, more inconsistent and late bedtime routines. In summary, the sleep difficulties in childhood tend to perpetuate, if not treated, a disturbed sleep in teens.

Conclusion

In a multicultural context (migration, refugees, etc) it is important to recognize the specificities of sleep associated with culture (Lélis, Cipriano, Cardenas, Lima, & Araújo, 2014). However, sleep is little discussed in the consultations of Children's Health in General and Family Medicine (only 7%, in a Portuguese study: Mendes et al., 2004). Mindell and Owens (2003) refer, in a U.S. study that more than 20% paediatricians don't question on sleep in routine queries of school-age children; and less than 40% question sleep habits in teenagers.

In addition, the behavioural problems of sleep and sleep deprivation are frequent in our country but culturally accepted by a majority of parents (Silva et al, 2013). Parents do not realize and are unfamiliar about the appropriate or normal behaviour in relation to sleep (Lélis et al., 2014).

Attempting that sleep and their particularities may not be perceived as a single measure, and as, because there is no consensus on the best way to sleep, we think it is advantageous to explore particular cultural strategies in the development of contingency plans in infant sleep, considering the impact that values and cultural beliefs have in asleep. As more ecological are the recommended sleep strategies, the greater will be the probability of adherence and success perceived by parents and children, with a restful and healthy sleep for the whole family.

Thus, it is essential to bet on early diagnosis of sleep disorders and promote preventive strategies (Mindell & Owens, 2003).

References

I. Cain, N., & Gradisar, M. (2010) Electronic media use and sleep in school-aged children and adolescents: A Review. Sleep Medicine, 11, 735-742.

II. Giannotti, F., & Cortesi, F. (2009) Family and cultural influences on sleep development. Child and Adolescents Psychiatric Clinics of North America, 18(4), 849-61.

III. Harkness, S., & Super, C. M. (Eds.). (1996). Parents’ cultural belief systems: Their origins, expressions, and consequences. New York: Guilford.

IV. Jenni, O. G., & O'Connor, B. B. (2005). Children's sleep: An interplay between culture and biology. Pediatrics, 115(1), 204–216.

V. Lélis, A., Cipriano, M., Cardoso, M., Lima, F., & Araújo, T. (2014). Influência do contexto familiar sobre os transtornos do sono em crianças. Revista Rede de Enfermagem do Nordeste, 15(2), 343-353.

VI. Mendes, L., Fernandes, A., & Garcia, F. (2004). Hábitos e perturbações do sono em crianças em idade escolar. Acta Pediátrica Portuguesa, 35, 341-371.

VII. Mindell, J., Sadeh, A., Kohyama, J., & How, T. (2010) Parental behaviors and sleep outcomes in infants and toddlers: A cross-cultural comparison. Sleep Medicine, 11, 393-399.

VIII. Mindell, J. A., & Owens, J. A. (2003). A clinical guide to pediatric sleep: Diagnosis

and management of sleep problems in children and adolescents. Philadelphia: Lippincott Williams & Wilkins.

IX. Mindell, J. A., Bartle, A., Ahn, Y., Ramamurthy, M. B., Huong, H. T., Kohyama, J. et al. (2013). Sleep education in pediatric residency programs: a cross-cultural look. BMC Research Notes, 6, 130.

X. Morrell, J. M., & Cortina-Borja, M. (2002). The developmental change in strategies parents employ to settle young children to sleep, and their relationship to infant sleeping problems, as assessed by a new questionnaire: The Parental Interactive Bedtime Behaviour Scale. Infant and Child Development, 11(1), 17-41.

XI. Owens, J. (2004) Sleep in children: Cross-cultural perspectives. Sleep and Biological Rhythms, 2(3), 165-173.

XII. Rigda, R. S., McMillen, I. C., & Buckley, P. (2000) Bed sharing patterns in a cohort of Australian infants during the first six months after birth. Journal Paediatric Child Health, 36, 117–121.

XIII. Silva, F., Silva, C., Braga, L., & Neto, A. (2013) Hábitos e problemas do sono dos dois aos dez anos: estudo populacional. Acta Pediátrica Portuguesa, 44(5), 196-202.

XIV. Simard, V., Nielsen, T. A., Tremblay, R. E., Boivin, M., & Montplaisir, J. Y. (2008). Longitudinal study of bad dreams in preschool-aged children: Prevalence, demographic correlates, risk and protective factors. Sleep, 31(1), 62-70.

XV. Sourander, A. (2001). Emotional and behavioural problems in a sample of finish three-year-olds. European Child & Adolescent Psychiatry, 10, 98-104.

XVI. Valentin S. (2005) Commentary: Sleep in german infants. The "cult" of independence. Pediatrics, 115(1), 269-271.

XVII. Weimer, S. M., Dise, T. L., Evers, P. B., Ortiz, M. A., Welldaregay, W., & Steinmann, W. C. (2002) Prevalence, predictors, and attitudes toward cosleeping in an urban pediatric center. Clinical Pediatrics, 41(6), 433–438.

XVIII. Welles-Nystrom, B. (2005). Co-sleeping as a window into Swedish culture: Considerations of gender and health care. Scandinavian Journal of Caring Sciences, 19(4), 354-360.

Chapter 7

Social Service

Adolescent Victims of Cyber Violence: Change of Role for Social Work

Antonia Picornell-Lucas, Cristina Herrero Villoria

University of Salamanca

ABSTRACT

When the adolescent and youth violence turns into harassment and it goes far beyond the school using technology to achieve its purpose, its identification and eradication becomes more difficult, showing the fragility of the social system. In order to diagnose the emphasis given in the scientific research in Spain to cyber violence and to identify its impact, a systematic review of studies conducted in the past six years was raised, identifying the type of study, sample and its characteristics, studied harassment modalities and results obtained, among other factors. Despite the methodological gap of the analyzed studies, the main result suggests that situations of Cyberbullying have experienced an increase in Spain in recent years, becoming by the unstoppable advance of TIC, although at different rates.. Different studies also point to the fragility of public policies in this context of vulnerability for adolescents, which also do not recognize or create opportunities for young people themselves intervene in their formulation and development. Therefore, it is necessary to reformulate community strategies that articulate the risk factors identified by providing tools which empower young people and society in general, beyond the criminalization.

Key words: Cyberbully, violence, Grooming, adolescents, social work.

Introduction

We live in a Democratic State, where all human beings hold rights, freedoms and duties that facilitate coexistence in peace. The acceptance of this reality should be understood from a very early age; therefore together with the family (backbone transmitter of values), education becomes the ideal setting to train democratic citizens with criticism, citizen participation, responsibility and commitment to Society. Thanks to the social progress made in recent decades and the interest of the media in making visible the coexistence among school children, the unique problems of this environment are reaching all corners of society (Justicia and Benítez 2006). This is causing an increase in investigations related to bullying among school children, the factors that affect the characteristics contexts and any other variable involved. In addition, as a result, giving rise to multiple material resources to eradicate the problem through the development of tools that allow its prevention, identification and intervention.

However, what happens when the bullying among school children goes beyond the school? The answer to this question is connected to progress in the technological world. Information and communication technologies have evolved and revolutionized spaces of great importance for the development of the human being, particularly in the communication fields over the years. The use of TIC by children and adolescents has experienced a dramatic increase in our country. The National Institute of Statistics (INE, its acronym in Spanish) in its survey on equipment and use of TIC in 2015 households, confirms that the use of information technologies by children under 15 years of age is very high. As for regarding children, who are users of computer and Internet, the number has increased to 95.1% and the 93.6%, respectively. On the other hand, 90.9% of this population group has a mobile phone. Taking into account the use that is given to mobile phones with Internet access, 27% of girls and children from 11 to 14 years old Spanish recognizes not turn off their phone. This percentage increases with age, so that among adolescents of 13 and 14 years only 1 of every 3 turns off their terminal (Cánovas and others, 2014). Such is its emphasis in our lives that we find teenagers known as "digital natives", boys and girls who have made use of technologies from very young (about 3 years). However, this handling is far from being responsible (Ruíz, López and Rivero 2013). The technology is a double-edged sword in the hands of untrained users and endless eager exploration that mixed with the anonymity provided by the network, may give rise to the most dangerous feats listed even as crimes (Galence 2011). They may lack sexual connotation -Cyberbullying- or be directed against sexual indemnity -Grooming-. The incidence of these phenomena is detectable in any country and in different social classes (Garaigordobil 2011). Since 1989, exists in Spain an international instrument that recognizes children as right holders, the Convention on the Rights of the Child (CRC) 54 articles that describe accurately the rights granted to infants and adolescents. The article 19 stipulates the obligation of all the obligate States to take legislative, administrative, social and educational measures necessary to protect the child from any form of violence or abuse -physical or mental- that could be exposed. In this sense, this means that all those boys and girls under age victims of bullying or any of its variations, have a right to protection

In Spain, Cyberbullying is a scant studied problem and analysis as opposed to Bullying among equals, a phenomenon investigated by the scientific community since the 1990s. Before delving into the harassment through the network, it is necessary to make mention to the Bullying, considered the prelude to it. The most widespread and accepted by scholars definition is provided by Dan Olweus (1998:10) who explains that "a person is being harassed when was exposed, repeatedly and so prolonged over time, to negative actions by one or more persons". And supplemented by Avilés (2006:82) who indicates that “it is a situation that has [...] intended to humiliate and abusively submit [...] through physical, verbal or social aggression with results of the psychological victimization and rejection group”. In addition, Irurtia and others (2009:79) set limit the development of bullying "manifested in the same group social nature" where it lives and has its roots in the aggressive behaviors. As any type of harassment, at school not only attentive against the person individually -physical, verbal, social gestural- but it is also directed towards a certain collective -sexual, racist/xenophobic, homophobic and transphobic- (Avilés, 2009). This excessive violence moved from school to the virtual space thanks to the progress of TIC, giving way to a Cyberbullying far more dangerous and harmful to who suffers. Despite being a phenomenon under construction/in progress, still no consensus among researchers, Garaigordobil (2011:235) summarizes some of the proposals and defines it as: «An aggressive and purposeful act carried out in repeated and constant way along or through the use of forms of contact electronic by a group or an individual against a victim who cannot defend themselves easily»

From the legal point of view, the crime closest to the Cyberbullying is collecting in articles 197 and 510 of the Spanish Penal Code, where offenses against the right to privacy is typified through acquisition and fraudulent manipulation of personal data, through telematics or traditional means; through the disclosure of confidential information to third person without authorization or where appropriate use it to exercise any kind of violence that harms self-esteem and image of the person, especially if he is a minor. However, the Cyberbullying is a recent way to harass that requires a valuation and radically different analysis. In addition to the need for providing it a specific space in the current legislative system, for the moment ineffective. However, in the case of Cyberbullying problems to treat a type of peer consequence criminal impact will be differ from one case to another depending on the age of the offender. As well, according to the organic law 5/2000 of 12 January in terms of criminal responsibility of minors will be charged criminally children 13 years by not flaunting the age of criminal responsibility set forth in the law (14-18 years) without prejudice to respond civilly for any damage that may have caused the victim. If we focus on the collective that brings the age necessary to be punished criminally, law distinguishes the type of offense committed: threats, insults, coercion, or slander. And because of this, the judge of minors brought the punishment that suits the characteristics of the offender, bearing in mind always the educational character of the LORPM1 and while safeguarding the best interests of the child at any time.

All behaviors that derive from any form of harassment are an attack directly against the integrity and moral dignity of the victim, who is publicly attacked by sending or publication (or posting) of texts or harmful, cruel images over the Internet or other digital media of communication, as for example: email, messages from the mobile phone, instant messaging, personal sites and/or defamatory line personal behavior (social networks recordings or e-mails). Aftab (2010) shows this aggression can develop directly (direct messages to other young people) or indirect (by delegation, using other accomplices- either voluntary or forced- to harass cybernetically). Apart from the imbalance of power, intentionality and reiteration, characteristics common to both forms of violence, the difference in execution environment (technological front physicist) quality (anonymity and invisibility), stage (outside the school), the duration of the harassment (continued and lasting) and the origin of the attacks (not always has them), compounded the difficulty of detection and therefore help (Avilés 2013). Its virtual social relationships, which reproduce the same inequalities and insecurities, are living at street, although its detection is made more complicated. Cyber-perpetrators enjoy total freedom to the anonymity that offer TIC, allowing individuals who had not attacked without an identity hidden, which further complicates the detection of the imbalance of power between victim, offender, spectator and contributor to the typology of the Cyberbullying, according to the actions carried out by the aggressor (Buelga, Cava and Musitu, 2010; Willard, 2006), ranges from the Flaming (intimidate people through Internet by means of insulting or hostile messages) up to the Grooming, going through online bullying, phishing - Phishing-, violation of privacy, exclusion, denigration, the Sexting or extortion. It is difficult to consider anyhow exhaustive classification and, on the other hand, there may be a relationship between some of these behaviors. Nevertheless, the literature highlights a worrisome Cyber behavior: Grooming or Child Grooming, since the action takes place between an adult and a minor. It is also the risk that more parental concern expressed about the frequency with which children and adolescents consume content on the network. According to the report of the Ombudsman (2010) 65.7% of adolescents between 12 and 18 years, connects to the Internet, at a minimum, once a day; what it can be seen that virtual interpersonal communication is high.

As in the case of the Cyberbullying, its definition is not completely limited, although it is considered as an approximation fuller offered by INTECO (2011:4): «harassment exerted by an adult through actions carried out deliberately to establish a relationship and emotional control 1Organic Law of Criminal Responsibility of Minors (LORPM, for its acronym in Spanish) over a child in order to prepare the ground for the sexual child abuse (explicit or implicit)». However in the Grooming, or juvenile sexual Cyberbullying, are given two distinguishing features: firstly, harassment is not unique among equals, but that the offender is an adult and, secondly, its intention is of a sexual nature. In addition, this typology is characterized by a sequence of steps that would make effective harassment (chart I). In the first phase, or home of the friendship stage, the Cyber-stalker sets a first virtual contact with the child to gain their confidence. In a second moment, initiates a phase of a relationship in which, already consolidated the confidence, and established an emotional bond, are exchanged personal and intimate information. Finally, the stalker requests the child to engage in sexual acts, sometimes with threats and blackmail if the child does not accept their claims; It is the phase of sexual component (INTECO, 2011; Montiel, Carbonell and Orts, 2009; Montiel, Carbonell and Salom, 2014).

Chart I: phases of harassment in Grooming

Grooming involves preparatory acts which, although sometimes not reach his intended assault and harassment against the privacy of the child. Therefore the last reform of the Penal Code -the 5/2010, June 22- also makes it an offense, regulated in article 183:

«who for sexual purposes, determine a person under sixteen years old to participate in a behavior of a sexual nature, or do you witness acts of a sexual nature, although the author does not participate in them shall be punished with imprisonment from six months to two years. If it hadn't made him witness sexual abuse, although the author had not participated in them, a term of imprisonment of one to three years shall be imposed»

In Spain there are few studies on the incidence and prevalence of the sexual Cyberbullying youth, not as well as in others, as for example United States, highlighting David Finkelhor for his research on online child victimization. However, the University Institute for research on Criminology and criminal science of the University of Valencia already is developing extensive research on online victimization. Their studies show that, in the Valencian Community, more than half of young people declared to have noticed on occasion that an adult trying to derive some benefit of sexual nature through Internet (Montiel, Carbonell and Orts, 2010) he or she keeping the erroneous belief that it can protect themselves (Montiel, Robredo and Carbonell, 2011). As a result, the youth sexual Cyberbullying required to establish diagnostic criteria in order to take appropriate measures for its prevention; and, above all, taking into account the traumatic event for the boys, girls and adolescents.

Studies related to the effects of any type of violence online agree that they may be physical, psychological and social, as well as difficulties in academic performance and school absenteeism (Ybarra, Diener and Leaf, 2007) Sourander et al., 2010), depressive symptoms (Patchin and Induja, 2010) Gamez-Guadix and others, 2013), difficulties in social skills (Navarro et al., 2012), stress (Estevez, Murgui and Musitu, 2009) and even thoughts suicidal (Hinduja and Patchin, 2010). And is considered the possibility of dragging sequels until adulthood (Arroyave, 2012; Ruiz, Riuro and Tesouro, 2015).

Methodological Design, Techniques and Research Sources

Objectives and hypothesis:

The overall objective of this study is to describe the evolution and the current situation on the Cyberbullying in Spanish adolescents during the past six years, provide recommendations from social work. The specific objectives that focuses are: OE1: Presenting a comparative analysis on the scientific work carried out. OE2: Analyzing the differences and similarities of the specificities of traditional and cyber harassment by checking the increase in the incidence.

Methodology:

The qualitative strategy used has combined several methodologies to improve the knowledge of the current reality of the Cyberbullying and Grooming and to offer possible solutions to this problem. It has been used the comparative method, in order to find similarities and differences (Sartori, 1984), which has allowed to confront and interpret the selected studies, after the prior systematization of the axes of analysis proposed. The geographic scope of reference selected has been the Spanish territory as a whole. From this criterion has deepened in the research carried out from the year 2010.

The study population is configured by previous research on this topic, limiting the search in the temporal range of the past six years and confined to the Spanish State. They were consulted the electronic database ISOC (CSIC), DIALNET, PSICODOC, COMPLUDOC, SCOPUS as well as codes of doctoral thesis (TESEO, TDR), proceedings of scientific meetings and publications from NGOs. Whose features are tailored to the objectives and research which would allow us to build knowledge aligned and disparate not determined as a criterion of choice. For a better understanding of the data, a script in which the categories of analysis were identified to collect in each investigation was designed: year of realization, geographical scope, sample and methodology used, studied type of harassment, incidence, characteristics of victims and perpetrators, opinion of minors and proposed intervention plans.

Results

In general the whole, many of the studies, which can be accessed, indicate marked differences between countries when searching cases of Cyberbullying (Garaigordobil 2011); on the contrary, large discrepancies are not appreciated in those investigations that are aimed at traditional harassment (Garaigordobil and Onederra, 2008).

Consulted studies (table I) have different characteristics in relation to research of Bullying, Cyberbullying and Grooming, both in methodology and analysis techniques used in the sample size or the variables investigated. As studies occur in time, the instruments for the collection of data become more complex, combining the quantitative methodology -face to face and virtual- and qualitative surveys -interviews- allowing thus the possibility of obtaining results closer to reality. According to the analyzed studies, 40% used quantitative techniques compared to 60% that makes use of a mixed methodology- quantitative and qualitative- unless in any case use only qualitative techniques.

Also the sample size varies between studies, regardless of whether they are national or international. He presented a smaller number of participants (n=625) is however the corresponding to INTECO (2013) Microsoft (2012) study reaches 7600 participants and the national study of (Calmaestra,J. et al., 2016) achieve involve 21,500 adolescents. And in terms of the type of harassment and the variables investigated also differ between the selected studies. It has been established that the Cyberbullying is the most studied form, although there is still the need for further Bullying and, timidly, appears a greater interest in Grooming. Variables analyzed in all of them, in general, focus on the frequency and duration of the harassment, the way it is exercised, used online media and the disparity of deployed behaviors for harassment (usurpation of profile, spreading false rumors, etc.)

Table I: Characteristics of the studies considered depending on the variables and lines of analysis.

If we stop the incidence of the Cyberbullying, referred to by such studies (chart II), shows a steady increase. While?, it is necessary to clarify the difference in the results obtained by Microsoft (2012) and INTECO (2013), in which the percentage decrease is mainly due to the number of subjects of the sample (almost the double in the case of this latest study).

Chart II: Evolution of the incidence rate of Cyberbullying and year of study.

Source of information: Own elaboration through the data obtained in the analyzed studies (Pfizer, 2010; (Microsoft, 2012; INTECO, 2013 and Save the Children, 2016).

But the progressive increase of the Cyberbullying in Spain since 2009, would be located in the middle of the global table with respect to the other countries where the phenomenon of the Cyberbullying, according to the study by Microsoft, has been studied (2012), as shown in chart III. The Spanish territory with 37% would occupy a place below India (53%) or Russia (49%) and would have to higher levels with respect to EE. UU (29%)France (23%) and United Arab Emirates (9%). And with respect to the Grooming, the percentage of having undergone rises, at the maximum to 1.7% of cases (INTECO, 2011; Save the Children, 2016).

Chart III. Incidence of the Cyberbullying globally (2012).

Source of information: Own elaboration from data taken from the study of Microsoft (2012).

Investigations consulted claim which the victims, who suffer more harassment online, are often girls. The percentage of female victims is far superior to men: 74% compared to 70% (Microsoft, 2012) or 8.3% against a 5.2% (Calmaestra, J. et al. 2016). As for Grooming, the figures soar, like indicating Villacampa and Gomez (2016) the girls are 60% more sexually harassed than the guys, percentages approximate to those provided by INTECO (2013).

Despite the fact at the analyzed studies allusions to the socio-demographic profiles and the motivations of the aggressor are minimal, it is estimated that attacks may be caused in 4.2% of cases as a result of the sexual orientation and 5% by the color of skin, culture, or religion of the victim (Calmaestra, J. and others. 2016). Also elaborates on the social characteristics and personality of perpetrators and victims, although in our country there are studies on the possible causal factors of Bullying; to a lesser extent of Cyberbullying. On the other hand, the chances of being a victim are duplicated when also serves the role of stalker, since the rate of harassment between people who tease or threaten third parties rises to 74% compared with 37% who are not aggressors (Microsoft, 2012).

All these investigations also explain the ways in which the Cyberbullying is exercised; modalities of harassment can take a physical form -active- or relational -passive-, or even both at the same time. In the cases of Cyberbullying and comparing data provided by INTECO (2009) and Calmaestra, J. and others. (2016), both the direct threat via mobile phone or the network and isolation in a social network or chat have experienced a significant increase. It has gone from a passive Cyberbullying of 5.9% and a CB active from 2.9% to a passive Cyberbullying of 9.7% and a 9.1% active Cyberbullying, although it can be seen that the largest increase corresponds to the passive mode, as happens in cases of Bullying.

Conclusions, Challenges and Proposals for Intervention from Social Work

In order to eradicate any kind of harassment within and outside of the school environment and to measure that types of violence explained -incidence, causes, consequences-, designing strategies for action that are adjusted as much as possible to the reality, these studies have multiplied in recent years at international level. However, when we talk about research in Spain the number of studies it is not so broad, while the results which is accessed offer a quite complex situation, reinforced by the unstoppable speed of TIC are acquiring and the widespread use of these by adolescents.

After rigorous analysis of the forms of cyber bullying in scientific production, verify that inside and outside the academic world the situations of harassment have a huge presence in the life of the boys, girls and adolescents, the Cyberbullying is produced in one of every four teenagers (Defensor del Pueblo, 2007). Results that match those obtained in other neighboring countries, as they highlight Patchin and Hinduja (2012), directors of the Cyberbullying Research Center. However, for the Ministry of health, social services and equality (2013), data of the Cyberbullying are not reliable; don't have specific indicators for evaluation.

National studies on the factors of the electronic harassment and the characteristics of the offender and the victim are not accurate. Although, in general, there is agreement on the existence of an asymmetric distribution of power in all harassment cases, says that girls are more likely than boys to any type of harassment, but, especially in the case of the cyber- victimization (Avilés, 2009; Buelga, Cava and Musitu, 2010; Calvete and other, 2010; Felix- Mateo et al., 2010). Thus, the study of ANAR Foundation and Mutua Madrileña (2015:80), referring specifically to gender-based violence, says that 65.5% of cases the violence occurs through technologies “conclusions expected to take account of the characteristics of relationships between adolescents”.

In relation to the characteristic elements of the Cyberbullying, solidifies the greater presence of passive mode from the active, almost reaching twice as many adolescents who suffer isolation and humiliation over the previous decade (INTECO, 2009; Calmaestra, j. et al., 2016). This fact shows that the aggressor may have as greater legitimacy before the execution of any of these types of abuse, because will be backed by the freedom and impunity that grants you the non- physical presence.

Previous analysis’s underlined the need for a consensus to be able to accurately identify these types of adolescent violence, prevent and eradicate them. In addition, "preventing and combating violence against children and girls is one of the most effective ways of combating the various forms of violence in society" (Calmaestra, J. et al., 2016: 76). Meanwhile, the body of scientific research, at the national level, from different disciplines, is experiencing growth, although the heterogeneity that present exceeds the ability to compare scientific results. The research on any form of online harassment -Cyberbullying, Grooming- must move towards a common discourse, with reliability, similar methodologies, specific indicators and giving priority to the perspective of the rights of the child as an instrument of research.

All research is reflected in practice and has an impact on the design of policies of childhood, in the elaboration of plans and legislation. In this respect, they are different authors and organizations which allude to the need for multi-disciplinary involvement of actors, specifically trained in Cyberbullying (Garaigordobil and Onederra, 2008;) Avilés, 2013; I NTECO, 2013; Calmaestra, J. et al., 2016). And all of this will not be possible without a convergence on the measurement of the magnitude of this problem. Perhaps not productivity of research results is a possible determinant of a public policy of assistance -in most of the cases- and little work with the community around these social pathologies; of the lack of a comprehensive strategy for the defense of the children before any type of violence.

Articles 19 and 28 of the CRC establish the obligations of States in the protection of the child against all forms of violence. For this reason it is necessary to assume a number of policy priorities from the children rights approach and community action, finding "channels of conciliation between objectives and individual needs and groups" (Shepherd, 2015:4). In accordance with this proposal, social workers, focusing on intervention with social actors, can provide coping strategies to the adolescents, providing permanent communication spaces, as social networks and other Web 2.0 applications offer it is, as well as a perception more precise about the fourth space of socialization, with its civic and ethical rules the same used in the physical world. To address this digital citizenship, the social worker can designing community models of prevention, promote the protagonist of the boys and girls in implementing programs against the risk of interactions online, articulate educational strategies that include media and information literacy from a humanistic perspective and criticism (Tejedor and Pulido, 2012:65- 72). This strategy will charge importance through linkages with other professionals, with the educational community and the society in general.

It is evident that the school also plays an important role in the reduction of any kind of harassment. It is a place of learning for interaction and the rupture of vertical relations and domination which are produced with the harassment. Aware of these ideas, teaching unions have raised a proposal to develop a law for prevention of violence in the classroom in order to eradicate the practices of bullying. Calmaestra, J. and others. (2016), law should both the victim protection measures (action of urgency, psychosocial, communicated to the family, separation of the aggressor, allocation of a support person, etc.) as other restorative justice with the aggressor (therapeutic support, accountability and reparation of the damage). But education is not synonymous with schooling, so the social work should also promote training opportunities in equity in non-formal and informal education, generating the acquisition of civic values, management of emotions to manage situations of harassment, dialogue and active listening and empathy. In this way could avoid the effect of "support to the aggressor" and join forces in defense of the victim (Fernández, Pericacho and Candelas, 2011; Raga and Martin, 2014; Ruiz, Riuro and Tesouro, 2015). However, should mean the children required active participation to reduce the impact of any form of violence (face-to-face or virtual). Involve the child, making effective the right to express their opinion and to be heard (art. 12 CDN), will produce positive effects on the children themselves (improvement of its capacity of confrontation) and services that come (quality improvement) (Biscione and Picornell, 2015).

Also the family, as the primary unit of socialization and development adolescent, has the ability to contribute to the reduction of any form of harassment educating in values, respect for others, freedom of expression and decision, in tolerance and responsibility; but also knowing the instruments that can identify and prevent situations of harassment. That is why Fernandez, Pericacho and Candelas (2011) insist on the participation of families in the school and in the promotion of "training workshops of a preventive nature", which can reduce the conflict school-family and get a joint responsibility to deal with these problems.

Having said that, the intrinsic problems of harassment inevitably manifest themselves in the community space and, therefore, correspond to all citizens who make up the society mission to avoid any form of violence. Community social work, educational and organizational processes, can help to raise the level of awareness about harassment, engage media, the population and own adolescents, so that they accept their responsibility, and to ensure the participation of the adolescents in everything that affects their development and well-being. This community action must create strong networks with interests and shared objectives (Pastor, 2015).

In summary, making the people aware of weight the education has on the future generations should be a main objective in any strategy of intervention against harassment. Along with this, it is essential to establish protocols and improvements in the project of prevention and intervention with the ultimate aim of ending the bullying at school and online suffered by thousands of children during their process of personal and social development, making also possible the reintegration of the offender.Finally, to promote research, that will become the opportunity to guide the policies of childhood, always integrating the perspective of the rights of children.

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Francês - The Story of a Helping Professional Relationship with an Institutionalized Adolescent

Sofia Veiga

PhD in Psychology. Adjunct Professor at School of Education of the Politechnic Institute of Porto

Hugo Ferreira;Pedro Ferreira

Master in Education and Social Intervention. Social Educator at Casa do Vale

Abstract​
This paper aims to reflect on the specificities for developing a Professional Helping Relationship with adolescents, focusing on the praxis and the role of each actor in the process of change.

Considering the life narrative and the relationship built between a professional and an institutionalized adolescent, this paper analyzes the importance of building a secure attachment that fosters a gradual growth, autonomy, trust and empowerment of the adolescent. Further, it emphasizes the relational attitudes that professionals should develop, such as acceptance, respect, congruence, belief in individuals and in their potential for change.

This paper also discusses the extent to which building a professional helping relationship in temporary shelters is a fundamental condition for the construction of necessary and desired changes in adolescents.

Keywords: Helping Relationship; Professional; Adolescence; Secure attachment; relational attitudes

Introduction

The definition of professional helping relationship encompasses contributions of different theoretical perspectives from distinct areas of knowledge, including psychology, sociology and philosophy. One of the most important contributions relates to Rogers (1961/2010) and his humanistic perspective. Underpinned by existentialist conceptions, this perspective emphasizes the importance of human interaction, subjective experience, self-awareness, freedom of choice, responsibility and finding meaning and purpose in life (Guerra & Lima, 2005).

Carl Rogers states that human beings are responsible for their own destiny and actions; they are free to define themselves and make choices; they have the resources to develop and understand themselves; and, in interaction with others, they demonstrate an actual tendency to evolve in their own potential.

In situations of emotional or social vulnerability, a person may need professional help. The helping relationship appears as a psychosocial intervention and includes “a relationship in which at least one of the parties has the intent of promoting the growth, development, maturity, improved functioning, improved coping with life, of the other” (Rogers, 1961/2010, p. 63). This relationship, built up over time, aims above all to create conditions so that the person in need of help is able to change and transform his thoughts and emotions in order to solve one or more problems (Chalifour, 2008; Timóteo, 2010; Simões, Fonseca, & Belo, 2006) and achieve “more appreciation for, more expression of, more functional use of the latent inner resources of the individual.” (Rogers, 1961/2010, p. 63-64).

For Rogers (1961/2010), the helping relationship is collaborative, non-directive and co-constructed based on the recognition of the capabilities that the other has to autonomously overcome his/her own problems and to self-actualize. The "best way to help the other is to believe in him/her as a person, in his/her capacity as a thinking being, with feelings and able to search for and direct his/her own need for change" (Simões et al., 2006, p. 47).

The professional is then a facilitator who is required to be genuine and to show unconditional positive regard and empathy. When developed under these principles, the helping relationship may lead the person to a significant learning, that is "learning which makes a difference – in the individual's behavior, in the course of action he chooses in the future, in his attitudes and in his personality. It is a pervasive learning which is not just an addition of knowledge, but which interpenetrates with every portion of his existence "(Rogers, 1961/2010, p. 324). When significant learning occurs the person comes to see himself differently, becomes more confident and independent and accepts his feelings more fully. In this sense, the person becomes more flexible, more acceptant of others, more open to the evidence, and more empowered (Chalifour, 2008; Rogers, 1961/2010).

For the development of this relationship, certain conditions need to be met: ​​"regularity of meetings; capacity to control his/her own life in order to effectively move towards the practical resolution of problems; independence (from family control, for example, in emotional terms); capacity to express tensions; stability, particularly of organic nature; intelligence that enables to reflect upon his/her own understanding and to face existential situations" (Timóteo, 2010, p. 38-39).

One of the aspects that distinguish a helping relationship is the asymmetry, given the different roles and functions of the intervener and the person being helped. This asymmetry does not mean that one is more dominant and active, and the other, more fragile and passive (Simões et al., 2006; Soriano, 2005). Indeed, both have significant and complementary roles in this relationship: the person who helps, facilitates the development of self-concept so that normal growth can proceed and the person who is helped, has in himself the inner force driving this relationship. Despite this interdependence, as stated Coimbra de Matos (2004), the responsibility is primarily on the side of the professional. This by no means implies that the professional should take part, impose decisions or decide by the person (Santos, 2004). Instead, the professional should be attentive and available to communicate and encourage the person to assume responsibility for the process of change and decisions to be taken. Communication is one of the key factors for establishing and developing a helping relationship. According to Salomé (1995), the quality of communication depends on the capacities of individuals to listen, understand, talk and let others talk.

While listening, professionals must receive and learn to accept what is told. This does not mean having to approve, but implies the acceptance of the other regardless of encountering certain issues that are not consistent with their ethical or moral values. It implies, therefore, “detachment” (coming off from oneself) and “intentionality” (making oneself available). This requires “proximity and distance” (Salomé, 1995, p. 41). Proximity refers to the need for the relationship to be empathetic; distance is justified by the fact that what is revealed belongs to who communicates and the professional must avoid comments and judgments. As stated by Capul and Lemay (2003), it is fundamental for the professional to continually take a double look, so that he not only listens to the other, but also he listens to himself and he thinks about himself in the relationship with the person who is helping.

Understanding involves the ability to comprehend the message in the variety of languages used by the person. Apart from verbal communication, the professional must be sensitive to the way the person presents oneself and poses questions, as well as the body expressions used. According to Coimbra de Matos, the helping professional is a “face specialist” (2007, p. 121). Only after listening and understanding what has been heard the professional should talk, always respecting the message and the linguistic code of the person. Often, the professional is guilty of “not listening to the other" (Salomé, 1995, p. 46), because the messages the other transmits are too coded or because the professional does not respect the time and the availability of the other.

Finally, letting the other talk should not be confused with an unspoken message, but rather with respect for the territory and the communicational time of the person, as well as with the possibility of using other languages that facilitate the process of building the helping relationship (Salomé, 1995). After this brief background, the case of Francês will be presented, followed by a reflection on the specificities of developing a professional helping relationship with adolescents.

Francês, a life story

Francês was born in 1992, being the youngest of four children. Due to the death of his mother and the resignation of his father from parental duties and responsibilities, he was handed to the care of his paternal grandparents. Due to their advanced age, caring for the grandchildren was not an easy task. Francês was the one that created more difficulties, namely through constant oppositional and defiant behaviors. At the age of eight, Francês lost the sight of one eye during a game with sticks with his older brother. This event represented a key moment in the relationship with this brother, with whom he developed a troubled relationship from then on, fueling feelings of anger and a sense of revenge.

Around the age of ten, Francês began to be accompanied by the Commission for the Protection of Children and Young People (CPCJ), after the school has denounced the case by school absenteeism. At that time, and following the intervention of the CPCJ, he started psychological follow-up and, later, at the age of fourteen, the support also has included pedopsychiatric follow-up. These supports were brief, as a consequence of the improvements evidenced in the school context. This development was sporadic, however, with the subsequent aggravation of his problems: school investment became less and less and behavioral problems worsened, with thefts of colleagues’ belongings and school materials. At home, similar episodes were repeated with grandparents. In addition, Francês spent more and more time on the street, without any supervision or defined limits, and the caretakers did not know where their grandson was or what he was doing. It was in this moment that he started smoking.

Francês had no friends at school and at home the relationship with his family was poor. The older sister, who was his main affective reference, had emigrated, keeping only occasional telephone contacts and visits on festive events. The only relationship that the teenager considered positive at this stage of his life was with an adult, a homeless man who was sleeping in an abandoned old factory near his home. Francês spent a lot of time in his friend's company, particularly during the period when he should be in school, helping the man in the task of removing copper from the building for later sale, buying him some food and even making some meals together in a space created for this purpose inside the building.

His grandparents began to demonstrate inability to cope, with repeated behaviors characterized by constant discussion and challenge, by active refusal to comply with family rules and by disregarding his mistakes, misbehaviors, school failure and absenteeism. The grandparents’ sense of helplessness led them to ask for help, resulting in the possibility of institutional sheltering. Before entering into the institution, Francês stated that he wanted to keep living with his grandparents, whom he liked and felt good with. Nevertheless, he recognized that he often did not behave properly, acting contrary to what was asked of him or expected from him.

The institutional sheltering

Francês entered into a Temporary Shelter Center at 15 years of age. His adaptation was swift and he rapidly understood the dynamics of the institution and related positively with all adults and peers. His life project was developed together with professionals and focused on the return to the family and on the attendance of a Professional Course, which would give him the equivalence to 9th grade.

At the time of his institutionalization, he attended 6th grade. As the school year was ending, the decision was to continue in the same school, even knowing in advance that Francês was negatively viewed by teachers, staff and his peers, particularly his classmates. Although he finished the year without significant improvements, especially in regard to the acquisition of knowledge, Francês concluded the 6th grade and this success was justified by some improvements in attendance and mainly by the school intention to free itself and free the student, so that he could start a professional training course.

Despite the positive relationship with the adults of the institution, Francês did not develop any relation of proximity that allowed him to have an emontionally meaningful figure of reference in an adult,. The teenager identified the relationships he had developed as positive. However, these were not strong and genuine enough to create the necessary trust environment for the change to occur. Lies and mistrusts were thus common features in his interaction and communication, particularly with the professionals that were closer to him. In fact, this pattern was already identified by his grandparents and brothers. During the meetings with professionals, they reported the difficulties in communicating with and trusting Francês and they recognized that sometimes they ended up being unfair to him. They described him as a young man closed off, silent and gloomy.

It should also be noted that the only relationship that Francês described as positive was, in fact, very fragile. He has never expressed willingness to look for the friend who lived in the abandoned factory, although, sometimes he referred to this friend when telling his past adventures to his new colleagues. By thinking that such hesitation was due to the fear that professionals would repeat the same prejudice he had previously heard in other contexts (due to his friend being homeless and much older) the team decided to visit this man in the place where he lived. He received the team in a friendly way, but described a different scenario from the one that Francês referred to. This man told the team about the teenager and demonstrated that he knew some things about his life. However, he also told them that he did not spend as much time with him as they thought. Although he sympathized with him, they did not have a close relationship. Moreover, he referred to feeling sorry for Francês, because he was always alone and appeared to be a sad boy.

Although, with the entry into CAT, Francês ceased to be as quiet and gloomy as he was at home - this factor was also highlighted by the family that found him different and better on weekends he spent with them - the pattern of his relationships did not change: mistrust, lies, self-closure, as well as the pursuit of personal benefits. As a matter of principle, Francês protected his colleagues of the institution when there was a problem, although he would also report inappropriate behaviors (e.g., absenteeism and thefts among colleagues), if he saw any personal benefit there.

It is important to point out that for many young people, the institutionalization is interpreted as a punishment. This is not far from the truth, since they are separated from their contexts, their families, their roots and their identity references. The cases of young people facing entry into an institution viewed as a positive factor are very rare. This notion, of being a punishment or a direct consequence of negative attitudes or behaviors, prevails (regardless of the family history). This is the starting point for change.

At the beginning of the next school year, Francês was able to enroll in a Professional Course in the area in which he had demonstrated motivation from the day he joined the institution. The admission to this specific course was not easy, because there were only a few spots for many candidates, but he was able to get in. After two months of training, the teenager was practically failing due to lack of attendance. However, he was given a new opportunity to initiate this training in a responsible way, after he assumed a commitment to change, with the class director. During a meeting with the professional in charge of his education and with the class director, Francês committed himself not to miss school and to seriously invest in the course. He did not comply with the agreement and was invited by the school to withdraw.

Faced with the fact that he did not invest in a project he had aspired, Francês did not take responsibility for his actions, as usual, arguing that "this was not what I wanted", "it was very difficult", "we never did anything practical, we just watched others do it". This posture allowed the team to foresee the difficult work to motivate and commit Francês with a life project.

After some time in the institution, a daily occupation plan was defined with Francês, which consisted of small repair tasks, defined according to his interests and oriented towards the acquisition of autonomy skills (cleaning, housekeeping, cooking and laundry). The deprivation of some privileges previously conquered was also set (including authorized exits and greater autonomy in managing his free time); on the grounds that, until then, he had not been able to properly manage his time. It was only from here that the teenager showed interest in entering a new course. The team sought to promote his enthusiasm, but was aware that his motivation was mainly related with the possibility of having a less institution-centered routine with more autonomy to manage his time and less effective supervision. This view was explained to him. If he could not find motivation in training, as an important part of pursuing his life project, but just as a way for spending more time on the street, he could hardly succeed. Francês had a very positive speech about his new life project and stated his will to change.

After a month and a half, Francês joined training in pastry and bakery. He started the training attending classes regularly and with a tight supervision of the team. However, this initial mood lasted just over a month, after when he started to miss classes. During the period of two months he left the institution daily at 8:00 am and returned at 8 pm, without anyone knowing where he was or what he did during the day.

Shortly thereafter, it was decided to take Francês out of the course, which in practical terms he no longer attended. It was also decided, together with the family and CPCJ, that henceforth he would spend the time at the institution involved in daily tasks, according to a plan of occupation, as if it was a job.

 Building and developing a helping relationship

The initial phase of this process was not easy. Francês lost autonomy in the management of his time and felt diminished. Unlike other colleagues, especially those close to his age and with whom he had greater affinities, he was very much controlled by adults of the institution. Also, despite not having a formative occupation, he had less free time. Necessarily, this change produced effects and Francês’ reaction was evident.

At this stage, the differentiated role assumed by a professional was crucial. Through daily monitoring, this professional sought to develop with the teenager a privileged relationship of closeness, empathy and mutual respect.

During the period when he was with the institution with a daily plan of activities, Francês fulfilled his tasks. It was a plan that included practical activities, namely carpentry and bricolage, household, scholar and also recreation tasks. This plan had an educational character and intended also to meet his main interests.

Although Francês’s posture was negative in general, the zeal, rigor, and competence with which he performed his tasks were valued. The most positive aspects of the work performed, the knowledge and skills gradually acquired were valued. Similarly, difficulties, weaknesses and even the lack of motivation in tasks were worked with the teenager in a positive perspective, always emphasizing his qualities and potential, identified first by the professional and progressively by him, in a clear process of self-knowledge and self-valorization. The intervention was towards the development of his capacity to change and act according to his own circumstances, positive or negative, mobilizing his knowledge, skills and aspirations, without neglecting his doubts, difficulties and fears.

This process was long and never linear. Several times Francês demonstrated an attitude of refusal, saying "no one can tell me what to do!". Faced with this declaration, the professional developed a feedback about the real dimension of what Francês had stated. Namely, according to the existentialist perspective, for the only reason we are alive and we can choose our own steps, we have the responsibility to always do the best we can. This is the immeasurable responsibility, to ourselves and others, of deciding our own way. Therefore, the greatest proof of independence (i.e., of being in charge of ourselves) is to give the best of ourselves. This message was emphasized with Francês in the institutional daily life, through different strategies and discourses and in various contexts, especially when engaged in tasks and in individualized spaces. The aim was to help the teenager to recognize his qualities and capacities, as well as to discover the inherent responsibility of decision-making, characteristic of the growing process. This work allowed greater complicity and emotional closeness, as Francês was able to establish with the professional a more genuine and honest communication, opening doors to a quality relationship and to the support that could be provided to him.

During this time, he began to show no interest in sleeping at his grandparents’ house during the weekends, as usually happened, in order to stay more time at the institution. This lack of interest did not represent a detachment in the relationship with them, but rather the awareness that he could find, in other contexts, affectively richer and more emotionally satisfying relationships.

Indeed, after the work developed in the institutional context of proximity and investment in him and in his abilities and skills, Francês showed positive developments in self-esteem, particularly evident in his communication about what he was capable to do. He also showed changes with regard to: self-image – demonstrating a greater care for his appearance and personal hygiene; the responsibility assumed in carrying out his tasks and activities, inside and outside the institution; the management of his free time. The professional of the helping relationship was always present in this process, taking an attentive posture, and, whenever necessary, of comfort and encouragement. However, the professional also gave him space, respecting and encouraging his progressive autonomy and individualization, without distancing himself from the young man.

After a difficult period – when he was faced with the new school failure, his dropout attitude towards challenges and with changes in his life that included staying all day in the institution and the close supervision of an adult - the relationship has evolved, namely in terms of confidence. Feeling that the professional was close and unconditionally accepted and believed in him – in his competences and potential for change and growth – Francês began to accept and believe more in himself and in others. This relational experience of closeness and trust enabled Francês to experience a new and safer relational pattern, guided by affectivity, but also by limits. This change extended to other relationships, visible in the greater emotional (not just instrumental) proximity to others, and by the use of positive strategies in the interaction with others.

Francês started dating a girl. He negotiated a schedule within his plan of activities, so that he could date. However, this was rarely complied and soon the teenager began to spend the night at his girlfriend's house. Professionals’ warnings against this behavior had no effect. He was dazzled by his first love and had the support of his girlfriend's parents.

This apparent setback was, however, seen by Francês as a step forward in his life. To demonstrate this to the professional, he complied with most of the tasks that had been outlined at the time of his withdrawl from school, trying to demonstrate that this love relationship was not an escape from his responsibilities, but an evolution in his life. This love relationship, the influence of the girlfriend and the acceptance of her parents had positive aspects. In view of the new situation, and together with his girlfriend’s parents, his grandparents and the CPCJ, it was decided that Francês would stay at his girlfriend's house three times a week. This agreement was followed by a specific work with the teenager on issues of sexuality and intimacy.

Very soon positive changes were verified. Under pressure from his girlfriend, Francês stopped smoking hashish. In his own words: "she said: that shit or me, choose! I had no doubts." He continued complying with his tasks at the institution and his relationships, both with colleagues and with adults, kept up the positive evolution. When he was at his girlfriend's house, he contributed to the improvement of the living space (e.g., repairing windows, blinds and furniture), as a way of repaying the affection he received and the acceptance he felt there. Not long after, Francês changed his residence to his girlfriend’s house. The CPCJ was informed and agreed with this change and the Temporary Shelter Center remained as an effective support for him, a resource center with the doors open in case something was wrong.

Shortly thereafter, Francês referred to not feeling well to live and eat in a house, without contributing economically. Supported by the institution resources, he started an active job search. He responded to various job advertisements in tourism and construction, and went to some interviews. A restaurant in the city center called him for an interview for the position of kitchen helper. With anxiety he said: "What I’m I going to say? I do not know how to cook! They will soon realize. I do not know if I’ll go to the interview". With the support of the helping professional, he realized that he had months of training in the same tasks that would be requested in this job, because every day he helped in preparing lunch and in organizing and cleaning the kitchen of the institution.

On the day of the interview, Francês, accompanied by the professional, arrived ten minutes before the scheduled time. After thirty minutes he left the interview with a big smile - "I did it! I begin tomorrow". He described that further to usual questions, the employer requested him to peel and chop an onion, and to peel and cut a potato into sticks. The teenager was very familiar with these tasks and he passed this test with distinction, beginning his professional career.

For three months he scrupulously fulfilled his contract of six days of work per week and ten hours per day. He did not miss a single day. However, the employer only paid the first month. Francês got discouraged and asked for help to solve the situation. This was not immediately given, encouraging him to autonomously manage the problem. However, after three months without receiving the salary, the helping professional involved in the situation had a hard conversation with the employer, informing him that the teenager was not alone. Francês received the unpaid salaries, but was fired. After this episode, he started a new search for work, but got discouraged after three months without results.

Meantime, his sister who lived outside the country invited him to spend Christmas with her. Francês answered that he would love to go, but with his girlfriend. With his sister approval, the teenager and the girlfriend departed for two weeks. During the check in at the airport a new learning occurred. He was underage – was still seventeen years old – and so, he could not board without his parents’ permission. He did not know what to do. His father, as usual, was absent and his legal representative (in this case the professional of the institution) could not take responsibility, since the guardianship was not delivered to the institution (but only the custody). The professional sent the official document of the court with the authorization of Francês’ trip. This document was sufficient to allow the board. Francês went on his first trip by plane, without, however, knowing what was reserved for him.

He returned, as he said, a different person: more objective and with well-defined goals. He expressed the will to join his sister, work and build a future in the country she lived in. His girlfriend was included in his plan, but she rejected the possibility of leaving her family and her country. However, she encouraged him to go and pursue his happiness, as she would do too. Once again, Francês sought support and comfort from the helping professional and decided to keep his new goals. After obtaining permission from the CPCJ, he said goodbye to his girlfriend and left, in mid-January, ending the institutional sheltering.

During the first two months he stayed at his sister’s house and started working with his brother-in-law. He phoned the helping professional, his figure of reference, twice a week. He said he was good and committed to be happy. In the third month, Francês got a job more suited to his interests, which he learned and performed, with pleasure. He returned to Portugal at the end of the summer, on vacation, to visit his family and friends. He went to the former girlfriend’s house to tell her parents the news of the new country and thank them for their affection. Francês requested that the former girlfriend, now in a new relationship, to always consider him a good friend. He also confessed to her that their relationship was one of the best things that ever happened in his life. Every time he returns to Portugal, he visits his ex-girlfriend and her parents, the institution, his grandparents and his siblings. The telephone minimizes distances and Francês maintains regular contact with Portugal.

Discussion

Being the helping relationship an "implicit shared relationship of intimacy" (Coimbra Matos, 2004, p. 29), the professional must know and take into account the personal characteristics and the developmental stage of the person who is helped. Based on the narrative of the life story and the relationship built between the helping professional and Francês, this discussion will reflect on the specificities of developing a professional helping relationship with teenagers in institutional shelters.

The request for help

The helping relationship can be requested by adolescents, but in most cases it is determined by services, such as the Family and Children Court, or by their legal guardians, parents or, if institutionalized teenagers, by the case manager / guardian professional. In such cases, part of the initial work is to inform the adolescents about the reasons that led to their referral and provide them the opportunity to tell their version of the story (Coutinho, 2006).

The intervention takes place when the adolescent, the family or professionals perceive and recognize that something is not right (that is usually evident by nonverbal behaviors).

Challenges of an intervention in the day-to-day life of an Institution

When it takes place in a Temporary Center Shelter, the helping relationship occurs and develops in the context of this shelter’s day-to-day life.

According to Pais (2002), the day-to-day life includes routines and breaks, making it relevant to know and understand what is routine, repetitive and regular actions, but also the disruptions in what is regular, that is, the unexpected.

In this case, the helping professional was very attentive to everyday life experiences of Francês in the institution and sought to understand his reality in the different dimensions – school, family, social relations and others – in order to realize how Francês thought, felt and acted towards the institutional and relational dynamics and the unexpected challenges.

In this sense, the professional assumed, according to Pais (2002), the posture of a traveler researcher, since he did not limit his knowledge about the reality of Francês to what had been shown to him. The professional tried to go further, showing curiosity and interest in knowing his reality, as it was presented in the “here and now”, walking through different paths, some already expected, others totally unexpected and invisible. By adopting a posture of active listener and giving voice to Francês, the professional understood his problems, needs, desires and potentialities. They defined together small steps and realistic, clear and specific goals of change (Soriano, 2005). In articulation with the CPCJ and other professionals (i.e., from school and training institutions), with his family and later with the family of his girlfriend, the professional sought to “Get educated in the everyday event” (Capul, & Lemay, 2003, p. 95), taking advantage of all the opportunities provided by the different contexts where Francês lived.

This was the context in which the relationship developed and strengthened, the need for institutionalization decreased and gradual changes occurred.

Building an attachment relationship

Considering the specificities of the institutional sheltering, the proximity and affinity between the helping professional and the adolescent should be desirable and inevitable. Nevertheless, for adolescents who have experienced relationships of insecure attachment or abandonment, building a meaningful and trusting relationship can be very difficult, as evidenced by Francês’ story. Therefore, the beginning of a helping relationship is often challenging. In these cases, it is particularly important for the professional to be attentive and sensitive to behaviors of weak attachment and to show himself as an affective and trustworthy figure, whom the adolescent can turn to, whenever he needs help. This paper described several situations in which the helping professional has been a protective figure, such as the support provided to Francês to solve the problem with the employer and the intervention to ensure that the commitments were honored.

The sharing of daily life over a long period of time, during an important and necessarily memorable stage in the life of Francês, enabled the development of essential ties to the establishment and strengthening of the helping relationship and which lasted beyond the sheltering time. The comfort and reciprocity achieved in the relationship allowed Francês to establish a secure relationship with the professional, that was essential to start his journey towards greater empowerment, responsibility and autonomy. It should be noted, however, that this was a winding path with advances and setbacks, which required the professional to show frustration tolerance, perseverance and belief in the teenager. These characteristics were fundamental to support Francês "in his condition of a thinking being, with feelings and able to seek and direct his own need for change" (Simões et al., 2006, p. 47).

The role of the professional and the adolescent

The quality of the meeting depends, to a large extent on the professional’s acceptance of the person being helped. This implies that the professional, more than physically present, is emotionally involved, showing maximum attention, respect, and unconditional positive regard for the person, listening with empathy and supporting him/her to enhance his/her sense of security (Simões et al., 2006; Rogers, 1961/2010).

By being honest, genuine and sensitive with Francês, and by being entirely with him, the helping professional promoted within the relationship, "the necessary conditions for the emergence of inner truth" (Amaral Dias, 1988, p. 133). For Francês, and for young people in general, being "momentarily submerged by an emotional relation far beyond the verbal level, encourages them to reorganize themselves, as they find an adult sufficiently secure and empathetic (but distanced from their drama) who can report what has been experienced, make sense of the unintelligible and so structure a universe that became cataclysmic" (Capul & Lemay, 2003, p. 101).

The Francês’ capacity of acceptance was visible throughout the process, since the professional believed in his intrinsic value, even when the teenager showed less adjusted behaviors - challenging and lying or when he gave up or did not meet the tasks and commitments. In these cases, the helping professional classified his behaviors and set limits, acting as a representative of the law (Capul & Lemay, 2003). The definition of limits proved constructive for Francês and helped him to know himself – as a person within a group / community / society - with rights, but also with duties and responsibilities. By being more aware of himself and others, he was able to act in a more adjusted and healthy way in the relationship with others. He was also able to build a path that was more in line with his interests and more realistic to his capabilities and limitations.

Rassial (as cited in Coutinho, 2006) stressed the need for the professional to constantly question the position he is occupying in the transfer: adult, master or accomplice. When taking the position of an adult, the professional can be rejected, by the similarity with the parents’ speech and attitude; on the other hand, the professional should not take the position of an accomplice, since the adolescent is looking for a master that clarifies his uncertainties, doubts and questions. The professional "should be able to answer these issues so that new meanings can be found" by the adolescent (Rassial, 1999, as cited in Coutinho, 2006, p. 50). In the story of Francês, the professional mainly adopted the role of a master, although at a certain time, he had to take the position of an adult, when he had to classify behaviors and impose limits and rules, essential for the teenager to organize himself.

The investment of the person being helped is equally important, because he/she is the protagonist of the his/her own process of change and who will outline the way forward (Simões et al., 2006). Francês was always involved in the development of his life project and, at the end of the helping process, he was able to autonomously define the course of his life, which he pursued with determination, tenacity and responsibility.

The helping process occurs in the interface between the characteristics and motivation of the person being helped and the qualities, know-how and investment of the helper. That is, "the relationship and involvement between the individual and the professional is what enables the creation and re-creation of the true individual: free, spontaneous and happy" (Coimbra Matos, 2004, p. 28).

Intervention strategies

The intervention with adolescents is complex and challenging (Bunge, Scandar, Musich, & Carrea, 2015). Often they resist. Thus, in addition to the relational qualities previously explained, the intervention must include humor, be playful, dynamic, creative. Hence, it is important to use different strategies, such as dialogue and leisure, artistic and musical activities. In the case of Francês, the strategies used included the involvement in tasks in the intitution’s day-to-day life and related to his personal and professional autonomy.

Dialogue - mediated or not by music and other activities - is the primary strategy for working with adolescents and was the most used with Francês. Nevertheless, adolescents quite often have difficulty communicating and expressing themselves orally, which can trigger or fuel conflicts with others. With this in mind, the helping professional – in addition to seeking to understand the meanings of Francês’ experiences – tried to adjust his language to the young man’s, to his circumstances, to the time and the developmental tasks he encountered. The professional made an effort to transmit clear and accurate messages, namely related to sexuality and intimacy, so that Francês clearly understood the content. The availability of the professional to listen, without judgment, to the doubts and concerns of the teenager, and the maturity to accept and hold his incomprehension, opposition and emotion were fundamental to this process.

It is clear, therefore, that Francês valued the professional who: listened to him, respecting his opinions; sought to maintain a distance, respecting his space; chose private spaces for the intervention, ensuring confidentiality; sat beside him, even without words, showing an availability and complicity.

Collaboration with families: a possible and necessary alliance?

To understand the person, the professional has to consider the reality of his life, which includes family, friends and the community, among others (Capul & Lemay, 2003). Regardless of whether the family asks for help or not, family should be, wherever possible, involved, in the intervention. In the case of Francês, his family had an impact in decisions taken during intervention.

Working with families, although important, can hinder the intervention with the adolescent, particularly if a tight connection among families and professionals is established. Within this context, Coutinho (2006) asserts that this is a controversial and problematic issue. In Francês, the family was involved from the beginning. Throughout the process, the family proved to be committed to his life project and available to be a part of it. His grandparents pledged to welcome him at weekends and his sister, with whom Francês had a special relationship, gave him the opportunity to access a new reality, under her protection.

Guided by the professional, family members and other meaningful people can be effective therapeutic elements (Kazdin & Weisz, 2010, cited in Bunge et al., 2015), as Francês’ sister.

Conclusion

Within a Temporary Shelter, the professional shares with adolescents key properties of human relationships: coexistence, closeness, affections. Like any other human being, these adolescents feel the need for affection and to be seen, heard, respected, valued, loved. They feel the need to have someone available to themselves, in whom they can trust and with whom they can share experiences and think - about themselves, about others, about life - and define paths.

Indeed, the helping relationship appears to be a particularly rich and relevant possibility for psychosocial intervention. This relationship focuses on the person being helped and is based on the belief that he/she has all the capabilities and resources to overcome adversities and to self-actualize.

Based on these principles, the helping professional should not, at any time, doubt the capabilities of the adolescents, regardless of the suffering and behaviors that they can show. Although a more directive attitude may be necessary in some moments and circumstances, the professional must look at these adolescents as individuals with potentialities and facilitate their empowerment and autonomy to reflect about themselves and define a life project, by implying adolescents in their own helping process (Soriano, 2005).

It is in this dynamic of mutual exchange of experiences and feelings (with a deep respect for each other) that they develop the ties and the complicity necessary for change to happen.

References

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Being Foster Family in Portugal: Motivations and Experiences

Elisete Diogo

Social Worker, PhD candidate, Catholic University Porto

Francisco Branco

PhD, Thesis Supersivor

Abstract

Foster care is an almost absent component of the child care system and the scientific research topic in Portugal (Delgado, 2007). Despite being established as policy measure, it only corresponds to 3,5 % of out-of-home care (CASA Report, 2015). The present research contributes to a deeper visibility of foster care, aiming to give voice to these foster families and understand their motivations and expectations, theirs needs and impacts on personal and family dynamics. The research adopted a qualitative approach, based on narrative interviews with foster families and focused interviews with professionals. The sample was intentional, covering 10 foster families (FF) according the criterion of maximum variation,. The qualitative data analysis adopted a Ground Theory orientation (Charmaz, 2006; 2014).

Results show that foster families’ motivation is rooted in altruism and supported by affection for children and sensitivity to child maltreatment. These factors, but also the family and professional biography and the contact with child out-of-home care induce a predisposition to become foster family. The family resilience to host children with traumatic experiences and disruptive behaviours, the quality of support, as well as the link with the fostered children after they leave, contribute to the renewal of the disposition to continue fostering. The FF experience is traversed by challenges and rewards. For the participants being carer is rewarding considering the recognition of the stakeholders. The positive experience of foster families covered by this research constitutes evidence to support the positive benefits for the Portuguese child welfare system to enlarge foster care as a response to child protection. The quality of services and the performance of social workers are a key element for successful foster care processes. This study contributes for public policy and for professional intervention.

Key words: Child Welfare, Foster Families, Social Work, Policy Making, Portugal

Introduction

Through European countries, welfare systems have a history and diverse responses to childhood well-being. Foster care (FC) is poorly represented in the Portuguese protection system. Despite being considered in legal terms the preferential response for placement of children, data show that, in 2015, from 8,600 children in placement, only 3.5% were in FC (CASA, 2016). The invisibility of FC is a reality even in the Portuguese scientific community (Delgado, 2007).

Foster Care in Portugal

According to the Portuguese Act on Protection of Children and Young People in Danger7, foster care consists on "the entrustment of a child or an adolescent to a single person or to a family qualified to do so, for providing him / her integration into the family environment and the provision of appropriate care for him / her needs and well-being and the education necessary for him / her integral development."

In Portugal, according to Delgado (2007), foster care, from its genesis to the present, can be characterized by: i) Predictability of return to the biological family; ii) Temporary placement; iii) Lack of definition of the concept of "foster family in a professional home"; iv) Restricted classification of the nuclear biological family, allowing placement in kinship family; v) Celebration of service contract and remuneration by the foster service provided; vi) Lack of campaigns to promote and disseminate the measure; vii) Lack of foster families selection and professional support; viii) Inexistence of initial training for the families candidates and of continuous training for the families in activity; ix) Low social and economic level of the foster families, associated with low levels of academic qualifications; x) Lack of associations that represent and support the foster families.

Foster care is mainly administered by the public service of social security, nevertheless there is an NGO called Fundação Mundos de Vida that also intervene. This foundation operates in Porto and Braga departments, what generate a greater expression of foster care in the northern region of the country. There are verified significant disparities in the national scope, in terms of geography and professional support.

The need of studying carers results from the fact that "much of the best and worst of the process of adaptation and subsequent development of a placement is due to the characteristics of the family who cares." (Amorós and Palacios, 2004).

Methodology

Based on the qualitative approach, the empirical design of this study consists on narrative interviews with the foster families and focused interviews with professional teams responsible by the recruiting, training and accompanying of the families, and case files analyses. Among the research questions we can mention: i) How and why do families become foster families? ii) What is the experience of the foster families in the measure of foster family? iii) What contributions can foster families give to improve the measure of foster family?

Sample

The theoretical sample covered a total of 10 families, with two different supervision organizations (one public, and the other a NGO). We didn’t intend a statistical representation, but obtain a socially significant sampling of the diversity of the situations found in the scope of the foster care. The criterion of “maximum variation - including few cases but as different as possible to evidence the breadth of variation and differentiation on the ground" (Flick, 2005: 71 citing Patton 1990: 169-181), complemented by the criterion of convenience, according to the limited resources, both economic and temporal. The participant’s families had biological or adoptive children. In-depth interviews took place, on average, over than 01:30 hours, half were family interviews. The selection criteria for foster families were: i) FF with biological children in the household; ii) FF with independent biological children; iii) FF at the first foster experience; iv) FF at the second (or more) foster process; v) FF that are ending placement; vi) FF that foster children with disabilities; vii) Ex foster families. In the access to the field there was the collaboration of the professional teams of accompaniment, namely providing the physical space for interviewing. The remaining interviews were conducted at the carers home or other location.

Data analysis

The qualitative data analysis adopted Grounded Theory orientation, in order to elaborate a theory empirically based, as recommended by Charmaz (2006, 2014). Using the software MaxQDA12, the theoretical coding had begin with a line-by-line coding, and later focused coding. At the same time, initial and advanced memos and diagrams were drawn up.

Results and discussion

The Process of Building the Motivation to Be a Host Family

The results of this research allow us to argue that the motivation of families to foster a child in situation of lack of protection is rooted in the values of altruism and is supported by the affection for children and the sensitivity to maltreatment that affects many children in our country. It is perceived that altruism is not unconditional, considering the importance of the well-being of the foster family itself. The valorization of the family, as a suitable context for the socialization of children, giving them the right to grow up in a family, is also at the basis to become a foster family. At the same time, it establish FF limits by making visible that provision for foster care is re-evaluated when childcare affects the established family balance. These results, observed in this study on foster families in Portugal, are consistent with other national and international studies, namely Schofield, Beek, Sargent and Thoburn (2000), Delgado et al. (2013), Howell-Moroney, (2014), Leschied et al. (2014). These authors also highlight the altruistic values focused on the child well-being or on the contribution to society; the desire to promote a good home for the child; to provide love for a child and a home to whom is placed in an institution; to help a child with special problems and help the community / society providing adequate levels of protection and development for children.

These aspects, associated with personal and professional biography, and direct or indirect contact with residential care or other contexts of deprotection, are according to the present study factors that contribute to the predisposition for families, from different types, to become foster families. This is an aspect that is less focused by the international and national literature on foster families, highlighting the contribution of this research to the study of foster care and particularly to the process of building motivation. In addition to the biographical component, which may be more evident in the study of attitudinal processes, the contact with experiences of deprotection appears to us as a suggestive explanatory element, namely for non-professional foster families. In fact, some studies show the influence of the professional trajectory of caregivers, as nurses, teachers or other professionals in the social área, working with children or families in need in the past, namely families with quasi-professional characteristics (Schofield, Beek, Sargent And Thoburn, 2000).

Other studies also point out, as motivation factors, the importance of knowing other foster families, or of the origin of new foster families being integrated by the children of old caregivers (see Nutt, 2006, Del Valle et al., 2008 and Delgado, 2007). In the present study, only one caregiver had known a foster family in their professional context, projecting the desire to help a child in the future, in a more intensively way, as in her daily life she has observed many children with great emotional and basic needs.

Advocacy for the cause of foster care, such as that one developed in a particularly active way by the NGO Fundação Mundos de Vida, however, it will only have an impact when the predisposition to become foster family is already anchored in the potential candidates. This study shows that the participants, during the process of sensitization and recruitment that this organization performs, were already previously predisposed to participate in the support to children in situation of lack, in a more or less conscious way. The billboards and brochures they difund, with appealing images of children, act as a driver that awakens perhaps a latent desire to welcome a child, or may induce the desire to become a foster family, expressed in particular by their own children. Positive reports of children and families’ experiences in videos that the NGO divulges feed and reinforce the predisposition, leading to the final decision of candidacy. Narratives show the importance of the diversity of approaches and media used in the diffusion and advocacy of the figure of the foster family.

Empirical data also show self-centered motivations, once foster a child can satisfy the ambition of fulfill personal desires ("The girl ... the girl I have never had, I do not know if you are understanding me ... I have a boy, I have never wanted having more "- foster carer), it provides fraternal relations to the only begotten son. It confers family well-being, joy, self-esteem, a sense of social utility, and can even avoid depressive sinals, giving meaning to everyday life, as an occupation and a company. Nutt (2006) noticed in her study that a participant whose mother committed suicide erects children as their fundamental meaning of life, “- Without them, I would be depressed.”, foster gave him a sense of life. The motivations can be child-centered reasons, self-oriented reasons and society-oriented reasons, with most families being involved in foster care for reasons centered on the child (cf. Maeyer et al. (1994), Rhodes et al., 2006). Howell-Moroney (2014) observed self-centered motivations, such as the desire to be loved by a child, in almost half of the participants in his study. It should be noted that he found more self-centered motives in people who had no religious motivations. Fostering can also be a way of gaining self-esteem, obtain an emotional reward, healing the wounds of the past or a competent form of employment (Schofield, Beek, Sargent and Thoburn, 2000). Satisfying the desire to "fill the empty nest" when biological children are older, the lack of hope of adopting a child or the desire to provide companionship for the child (Leschied et al, 2014) are other motivations pointed out in the literature.

From the point of view of economic convenience, often associated with the dominant social representation of foster families, our study is consistent with the results of other international investigations (Nutt, 2006; Doyle and Melville, 2013). As the results show, carers do not express economic interests in the first instance, stating that money does not count, and considering that children receive unconditional love and are beyond the value they receive. Although it is observed, as it is mentioned in the testimony of a support team, that there may be candidates with economic interests, especially when considering foster care as a replacement of a job. Carers, in their testimonies, do not seem to regard foster care as a way of professionalizing women, focusing more on the domain of personal and family fulfillment and / or as a healthy occupation. In any case, as pointed out by the professionals of one support team, it is not the fact that they receive a value compatible with their performance, and with the expenses inherent to the child "that makes the measure less affectionate". This dimension gains an added significance when considering the limited values that foster families in Portugal receive from the welfare system as a reward for community service and reimbursement for the increase in family expenses with the child. Foster families end up making personal sacrifices they should not have to make, even though participants understand that this is part of the commitment they have made. Based on the literature, however, Delgado (2007: 45) points out that the trend that has taken place at the international level shows that there is a tendency towards professionalization, despite the apprehensions that can be verified regarding the disappearance of informality and altruism that characterize the foster care.

It can be concluded, as can be seen in diagram 1, “Producer Factors of Motivation for Being FF," that the motivation of these families is rooted in the values of altruism, supported by affection for children and sensitivity to unprotection. These factors, associated with personal and professional biography, and direct or indirect contact with the residential or other contexts of lack of children protection, produce a predisposition to become a foster family.

The Experience of Being Foster Family

From the point of view of the foster experience, it is lived by the carers with challenges and rewards. For the study participants, being a foster family is a rewarding experience considering the recognition of the child, the family, the community and the professionals. Even in those situations where the carers considered giving up and / or placement with a lot of negative aspects, they continue to say that it was "worth it" and that they would repeat every step. Personal and family development, as well as the positive impact on child development (see also Amorós and Palacios, 2004; Nutt, 2006; Delgado et al., 2013) are the most valued points in the experience. Aspects also pointed out by the professionals interviewed.

The arrival of the child is a moment of joy and emotion. The child is wanted and integrated as if he / she was another family member, like that referred to by the experts and by the studies of Oliveira (2012) and Blythe (2013a). Relationships assume characteristics of parenthood and fraternity, including within the extended family and the group of friends of carers. Personal and family dynamics really change. However, changes are viewed as naturally occurring during the process. Adjustments are made in physical space, schedules and routines. In a more contrasting position, Nutt (2006) points out that foster can change the lives of foster families completely, since the system expects that they will be much more than just carers. The professionals of one of the teams remember that to the foster family is requested to be open to receive the child, their family and the professionals of the various services related to child protection system, namely the presence in a court (Nutt 2006). Tribuna and Relvas (2007) admit that the conciliation between the different subsystems of foster family (biological parents, children, foster families and services) can complicate the experience for the carers, admitting that clear communications and relations between them can bring stability to triangulation which is established.

Among the participants, the procedures and the articulations with the services are understood as being part of the process, aware of the demands of the function they have assumed. They are available to receive the support team, as well as to arrange visits with the biological family. The data collected indicate that for the carers it may be complex to have children whose parents are different. Scheduling with one or two mothers and in parallel with one or more fathers leads to a family overload, from the point of view of expenditure and time, such as with travels. This is an aspect that indicates that for foster families when it is foreseen the maintenance of the contact with the biological family will facilitate to welcome germanic children.

Only two of the families take on the wear and tear caused by their experience, and they will therefore consider stopping foster. The fatigue is directly related to the behavior of the child they place, and may experience moments of instability. However, seeing the satisfaction of the child mitigats it and rewarding the experience. Nevertheless, in the study by Triseliotis et al. (2000), some carers admit the need to take a break to rest between the placements. This study does not show this need, and may even be considered to contradict this thesis, since the more experienced families are even the most available to continue to foster uninterruptedly. There is a greater overload in carers whose husbands are less active and involved in care due to the schedule, place of work or motivation for foster care. Heslop (2016) argues that male and female carers are underestimated and stereotyped, understanding that they have great skills in the education, care and discipline of foster children, suggesting that coaches help the carer as a man to negotiate roles in foster care. From this point of view, we can see the importance of family support and cooperation among family members. Carers are the main providers of care for both the family and the foster child. Overloading is reduced and family satisfaction increases when there is a fair distribution of tasks (between carers and even with their own children).

Both teams interviewed are unaware of the existence of foster families who have effectively ceased fostering on their own initiative. Children tend to be satisfied with the presence of the foster child and to collaborate in the provision of basic care, supervision, play and schoolwork. They build a fraternal relationship. They admit jealous in some situations, considering that they share the attention of the parents with the foster child. Some carers claim to give more attention and time to the foster child in detriment of their children in an attempt to make up for what they have not had in the past. They try to compensate for the negative impacts of foster on the children, using strategies such as auscultation of motivation for foster care; awareness of the characteristics and life course of the child; planning alone moments (parents-children) without the presence of the foster child. The international literature (Höjer et al., 2013) also suggests that Involving children in the decision to accept; Informing them about foster care and about each child ; Identifying protected moments for their children; Limiting information; Discussing problems; and Preparing them for the ending of the foster softens the impact. By experiencing foster a child, children can develop values of solidarity, sharing and fraternity or just suffer and revolt, creating conflicts. In denial situations, in order to protect the family unit, carers tend to consider giving up receiving and delaying new placements. Nutt (2006) has obtained significant results, from children of carers who are marginalized by the lives of their parents, while fostering, evoking the role of the authorities in the protection of these children. As this is an undoubtedly relevant issue, the evidence gathered seems not to be enough to confirm the marginalization or the need for services intervention in the protection of the children of carers. However, it is possible to admit that younger children may suffer more from fostering than the older ones, considering that they require more attention from the parents. The foster families in the present study are those whose children seem to have suffered from receiving another child, and who say that in the future, when the children are older and eventually independent, they intend to become a foster family again.

The relationship with the child family of origin is generally described as positive. There were only conflicts in one of the carers. The foster family tends to empathize with parents, reassure them, and share educational strategies. They often perceive economic and material shortages, providing food aid as an example. Helping the biological family, they intend to help the child. The family of origin, in some cases, becomes part of the foster family, given the frequent contact and sharing of daily life, namely the task of caring for and educating the same child, an aspect confirmed by Cleaver (2000) and Nutt (2006). A good relationship with the biological family will mean maintaining contact with the child after the placements has ended, which is one of the foster family's greatest wishes.

Many participants understand that they both respect the right to live with the child and share parenting as noted by Riggs (2015). Tribuna and Relvas (2007: 65) consider the concept of paradoxical double parenthood, understanding that "the child is subject to communication with two logical levels [between biological family and host family] irreconcilable." On the one hand, a loyalty parenting of the subsystem of the parents, expressed tendentially non-verbally (happening directly to the act), with passivity and social maladjustment and, on the other hand, a functional parenthood of the subsystem of the foster family, which expresses itself verbally and values adaptation to normative social values.

Curiously, regardding contact with the families of origin, the interviewed teams have different opinions, ranging from a view that emphasizes the availability of the foster family to the relation with the family of origin, and the one that indicates the difficulty / incapacity to deal with them. Both Riggs (2015) and Nutt (2006) in their studies admit that foster families have a fragile and ambiguous role when compared to the family of origin and to the professional, from the point of view of legal power and authority.

In line with national and international studies (such as Amorós and Palacios, 2004; Martins, 2004) and with the supporting teams, the greatest challenge seems to be related to the management of the child's challenging behavior that they foster in their space of intimacy. They perceive and respect the characteristics and life history of the child. They use strategies they have used in the past, with their own children, showing that the experience with children gave them more skills. Delgado et al. (2013: 27) points out that “carers do not enjoy equal decision-making freedom in relation to their children, nor can the behavior of the children in question be compared in most situations to their behavior. To steal, to lie, to destroy, to beat, to take drugs, to escape are some of these behaviors.” For these families fostering means to form, but above all to re-socialize, admitting that it is a complex task. The results of this study are similar to Nutt's (2006) research in that it reveals that carers try to understand and get explanations for the child's behavior, yet the difficulty is also in perceiving "what was really going on in the mind of the child" (Gilligan, 1996). "Truly cares" about the child is an expression used by different families, emphasizing that selfless motivation and affection seem to be central to successful placement. Resilience to manage stress will be a key family trait for success.

The capacity for family resilience is especially important, because foster families experience stress with the anxiety caused by the waiting for the child. They do not know how long it will take, the procedures, and the fear that fails. Often stress continues throughout the placement and after the end. In the same sense as pointed out by Delgado et al. (2013), coupled with the challenges, foster families receive several rewards, associated with the changes they make in the development of the child and the recognition and affection that it conveys. Some participants report that a child's smile is enough to reinforce resilience.

Adequate support is a urgent need, especially from the point of view of behavioral management, often lacking specialized intervention. Cares appreciate the relation, availability and appreciation of professionals. The support, family and friends, is also fundamental for the success of the experience, being the social support also pointed out by Ciarrochi, et al. (2012).

One of the fears most emphasized by the participants is that of the cessation phase of the foster, namely the loss of contact with the child with whom they have created a deep relation. Schofield and Beek (2005a) affirm the importance of attachment to placement success. Carers often disagree about the future insertion of foster children, understanding that the best interest for the child would be best kept in the foster family. The FF can feel a double suffering at the end of the placement, first by perceiving the child's desire to continue in the family and then by feeling the absence of the child with whom they shared the intimacy. Experienced families develop strategies to facilitate untying, which should merit the attention of the services, namely to accommodate two children, tending sisters, simultaneously to support each other upon cessation and to create a strong primary network based on family and friendship relationships, of high emotional support, in order to fill the feeling of emptiness when the children leave. Maintaining contact with the child after cessation; The preservation of memories through photographs, videos, and other memorabilia; The reception of new children and a process of preparatory transition carried out in a progressive manner, alleviate the anguish. There is a difference in the opinion of the professionals interviewed, since in one case the acceptance of the transitional character of the measure by the foster families is emphasized, in another this provision is considered critical. This study shows that families when they contact the service to apply for the foster, have a social image that can keep the child in their household until adulthood, admitting some disappointment as soon as they receive more information. It also shows that families accept the transitional nature of the foster care measure and they are aware that the cessation will occur. Although it is a time when they anticipate some suffering, they are satisfied that they can continue to contact the child and see her / him well after the end of the placement. Family support at this stage should not be overlooked. Delgado (2007: 262), based on studies and research projects, suggests that the competent entities can "admit the possibility of adoption by the carers, fulfilling certain requirements and according to well-defined criteria." Possibility that most of the participating families would indisputably, and that as researchers, we admit, in many situations, to be the answer that best suits the best interest for the child.

Desattachment differs from situation to situation. Biehal (2014) identified 4 types of perception of attachment in foster care: "as if" (almost adoption), "as" (were other parents), qualified (with feelings of hurt and ambivalence towards biological parents) and provisional (in the cases in the cessation phase).

Essentially, as Palacios (2015) points out, it is important to prepare for the transition. There is ambiguity, on the one hand, to the foster family is asked to be actively involved, creating a relationship of affection with the child, and on the other hand, the transitional nature of the measure is emphasized (see Delgado, et al., 2013).

As mentioned, the maintenance of contact with the child after the cessation reassures foster family, which is an aspect foreseen in the Manual of the Key Processes of Foster Care (Manual dos Processos-Chave do Acolhimento Familiar) and in article 34 of DL 11/2008 of January 17, considering the favorable opinion of the professionals and the agreement of the biological family. Delgado (2013; 2007) justifies it with the affective bonds that were created during the reception, being able to remember the common history, distancing itself gradually and naturally. The desire of the foster families to preserve the relation with the children, shows that it was not a utilitarian but emotional attachment and it is beyond the immediate character of the process. Attachment is built and maintained after cessation.

Some participants are emocioned when talk about fostered children they have not contacted for years. These aspects indicate that the foster families accept the transitional nature of the measure ("not staying with children forever"), considering the possibility of maintaining future contacts and occasional living.

Renewing the Disposition to Continue Being Foster Family

In a third dimension, our study shows that family resilience to accommodate children with traumatic experiences and challenging behaviors, quality of services support and maintenance of contact with the child after cessation, contribute to renew the disposition to continue being foster family.

Impacts, the rewards system and the management of desattachment are also clearly influential. Impacts are on the management of expectations, daily life, impact on biological / adoptive children and the management of children's behavior. The system of rewards for the experience, fed by the valorization and recognition (coming from the child, the biological family, the extended family and the support team); by support provided by social services (quality of emotional support, instrumental support and legitimacy attributed to their role), as well as the legal framework (legal autonomy, material rewards and status). Finally, the management of desattachment, in particular the quality of the preparation and supporting of the transition of the child at the end of the placement.

The happiness that the child shows that being with the foster family, the feeling of belonging to that family and the evolution they are having, represent for the FF a compensation and recognition for the "effort" or contribution they do everyday.

The extended family and the friends of foster family contribute to the process of personal satisfaction in acting in solidarity, when they recognize social value to carers, praising availability and encouraging continuity. In the present study, only one family was not supported by the extended family or by friends, and consequently conflicted with some relatives. Later, the placement was stopped, carers say that there is a possibility of returning to be a foster family in the future.

Respect, reinforcement, support and recognition of professionals and services are also fundamental to indicate that they rely on the capacities and performance as carers. In the opposite, in situations in which professionalism of the teams is not seen and the support is not adequate, carers are discouraged. In the event of a conflict between the foster family and the child, when carers understand that the team takes the side of the child in detriment of the foster family, they feel accused, discredited, unnecessary, useless. Their performance is undermined despite the effort they may be making, but on the contrary, it is important to legitimize their role and status for successful placement and maintenance of the host families experienced in the child.

From the perspective of the future availability to foster a new child, it is considered, based on the results of the present study, that foster families can be classified into three distinct groups: "unconditional", "hesitant" and "retired". The more experienced foster families feel foster care as if it were an "addiction," they do not imagine without children, they are available to foster two or more children simultaneously and want to be foster family until something prevents them. Friends and family encourage and support them. The "hesitant" foster families (and those who have stopped fostering) are in the first placement, experiencing some challenges that make them oscillate. The encouragement of the people close to them is fragile. The children or the husband tend to appear to not take care of more children (especially in the case of the families that stopped foster, which have been designated in this study by ex). The designation of "retired" may be used to foster families who do not intend to accommodate more children because of their age, they feel too old, cares that are already grandparents and suffering loss of capacity. They wish to dedicate themselves to their own family, and are not supported to foster new children.

In the opinion of one of the supporting teams interviewed, foster families expect to be rewarded with gratitude for the task they carry out, considering that it is socially expectable that the parents are properly caring for their own biological children.

Professionals consider that the family's disposition to foster new foster children may be correlated with the quality of the previous cessation, with the sense of accomplishment, or with the realization / frustration of the initial expectations. In fact, the study revealed that one of the participants understood to give up the placement, after a painful, and understood as unsuitable cessation, however, with the intervention of the support team they again fostered other children, remaining as "unconditional" carers.

Efforts to increase the number of placements in foster care through the recruitment of families are not enough. The support, training and professional consideration given to carers after starting foster is a great need. Delgado (2007: 45) also argues that the financial margin allows providing a freedom of choice that contributes to the retention in the system of existing foster families and to the attraction of the new ones. There is a diversity of studies with results, implications for practice, programming and policy analysis (Denby et al., 1999) that professionals need to take into account in intervention with these families in order to ensure the satisfaction and successfull placements. The authors' results lead them to reinforce the need for organizations to make timely decisions (particularly in terms of bureaucracy) reflecting a shared commitment with carers for children well-being; Must deal consistently with carers whose motivations must be respected, roles kept clear, and treated as team members. They further conclude that the foster families should have easy access to their support service and have rest periods between placements and that professionals should consistently address the needs of the foster families for fundamental information and for sharing experiences with other foster families. Another conclusion is that, as foster families seem to want to use competences, solidarity and skills, the more experience they have, the more likely is the continuity, as evidenced in the present study, with the foster family profile designated as “unconditional” characterized as "addicted to childcare.”

Implications for Practice

The positive experience of foster families in this study shows the importance of extending and strengthening foster care in the Portuguese system as a privileged response in the placement of children. There is no evidence pointing to the need for reservations regarding the preparation and performance of carers in Portugal. The attachment in foster is not utilitarian as it is maintained after the end. The quality of services and the performance of professionals are a key element for the success of fostering. The genesis and implementation of this measure have significant disparities in relation to current legislation, as well as the follow-up and discourse of the participants in this study, foster families in the public service, vs foster families in the NGO service.

There are some inconsistencies that need to be resolved:

Interest of NGO on implement foster care, but there is a non-implementation of new protocols by regulatory organization.

Families with interest in being foster family, but also professionals who do not know what to answer to potential candidates.

Families waiting to foster, but also a large universe of children in residential care or in danger in the family of origin.

On the one hand, committed foster families and undervalued, but on the other hand negligence and lack of protection from biological parents.

Children who aspire to have a family and judges / social workers who wish to ordain foster care, but the reality is that the protection system that does not have a foster families set.

This research constitutes a contribution to the public policies, and to the professional practice, suggesting:

i) Policies that translate into positive practices at the local level;

ii) Move towards current national and international legislation and recommendations;

iii) Promote studies and data collection coming from all the actors of the foster care;

iv) Make protocols between the welfare public service and NGO that show interest in the implementation of the measure;

v) Sensitize and adequately inform both the population and professionals working within the framework of the child protection system (courts, CPCJ, ISS, IP, among others);

vi) Disseminate and promote a positive social image of foster care and foster families;

vii) Invest in the recruitment and maintenance of the experienced carers for greater flexibility of responses / placement offer in foster care;

viii) Value and encourage foster families and professionals (with training, supervision, tax, social and labor benefits, reimbursement of expenses, and so on), a unanimous aspect in the discourse of carers and professionals interviewed;

ix) Consider the initial expectations and predefined criteria of foster families in the matching phase (child-foster family initial correspondence);

x) Maintain regular contact and feed the motivation of the families available on the stock exchange;

References

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Chapter 8

Sociology

Interculturalism in Adolescents and Young People of Île-de-France Region

Marta Maia

Abstract

We observed the socialization and love relationships of young people from 14 to 20 years of age, in different schools and social contexts. On the one hand, students of two public schools in Montreuil-sous-Bois, the high school Jean Jaurès and the college Fabien, which encompass students from various cultural backgrounds, coming from the middle and lower classes; on the other hand, students of two private schools, the Notre-Dame de la Providence Institution and the high school Gregor Mendel, in Vincennes, whose student population is culturally more homogeneous and emerges from the middle and upper classes. The relationships and behaviors of these populations fall into social contexts of greater or lesser interculturality and of bigger or smaller social vulnerability.

Keywords: School, interculturalism, youth, love relationships, socialization.

Introduction

The periphery of Paris is a plural territory, covering diverse social realities. However, the simple term that designates the suburbs – banlieue - encloses in itself the image of the neighborhoods where the disadvantaged classes and the majority of the immigrant population are concentrated.

Montreuil-sous-Bois (hereinafter referred to as Montreuil) is a city with about 100 000 inhabitants, of whom one fifth are foreigners and a few other workers. The unemployment rate is almost twice as high as the national average (INSEE, 1999a). On the contrary, Vincennes is a city of 45 000 inhabitants which has an unemployment rate below the national rate and whose population has a socio-economic situation higher than that of Montreuil: 20.3% are cadres and only 11.5% are workers. Foreigners represent 8.7% of the population (INSEE, 1999b).

The schools that serve as the basis for this research are in the image of the cities where they are located. The Institution Notre-Dame de la Providence (hereinafter referred to as Providence), next to the gardens of the Town Hall of Vincennes, welcomes about 500 students from the second cycle to secondary education. Their entry is effectively guarded by a supervisor. Only students in the last two years of high school can go out during free time, with the youngest being inside the school all day, except for those who do not eat lunch in the canteen and are allowed to go out for lunch.

Gregor Mendel High School, in the town of Vincennes, is also small in size, enrollment is paid, and students like the school, which has good material conditions.

In Montreuil, Jean Jaurès High School, a large group of gray buildings and a little degraded, is attended by more than 700 students and facing some problems of indiscipline and delinquency.

The Collège Fabien, with students from the 6th to the 9th year of schooling, is surrounded by cités, groups of buildings where the most disadvantaged sections of the population are concentrated with problems of social precariousness and juvenile delinquency. It also has about 700 students.

The choice of schools was related to the profile of their populations and the surrounding social spaces, with varying degrees of social vulnerability.

The research methods used were semi-structured interviews, informal conversations and direct observation. Twenty interviews were conducted in each establishment, a total of 78 respondents, 32 males and 46 females. The individual and group interviews were recorded with the consent of the interviewees and carried out outside school, after school or at lunchtime, in the street or in surrounding cafes. In order not to be identified with the educational system, I contacted the youth directly and out of school. This option was motivated by the need to establish a relationship of trust with the interviewees and avoid any suspicions regarding the school system. Still, some of them asked me if I was part of the school administration or whether I was a teacher. The fear faded after information about my student status and the nature of my work with the student population, and confidence settled with the conversations and encounters. Fieldwork ran from November 1997 to January 2000.

The city and the school

The identity building of the young is adjusted by the cultural and symbolic capital proper to each group (Bourdieu and Passeron, 1964). It is expressed, for example, in tastes, in clothing, in language, in body language (Bourdieu, 1978), in the value attributed to material resources and school results, as was found among young people of the upper classes, or Physical, verbal or psychological, as observed in the socially disadvantaged population, as also noted by Lepoutre (1997) and Duret (1999). These differences echo social inequalities in the face of school and culture (Bourdieu and Passeron, 1970).

We have observed, like Avenel (2006), that the type of educational establishment that is attended has an influential role in the construction of social identity and in the social relations of young people. It is at school that they spend most of the day and weave a large part of their relationships of sociability. The school environment is therefore an important factor in the construction of social identity and sociability, as well as a form of access to a given social category. In fact, being enrolled in a private and selective school, such as Providence, means attending a population with a high social status and learning how to behave in terms of that social belonging, inserting a group that has codes, values, Representations, attitudes and behaviors. One learns to be a member of a group by adhering to its culture (Duret, 2008). The school system redoubles, thus, the action of preexisting social determinisms (Bourdieu and Passeron, 1964).

Enrollment in that private school presupposes that the student obtains good school results, has some economic capital and is willing to obey a wide set of rules imposed by that establishment, where it is forbidden, for example, to smoke, to have games, to play electronic games, to use cap, have long hair or wear earrings for boys, dress in a way considered provocative or sloppy for girls, etc.

In turn, public schools receive pupils of diverse cultural backgrounds and social conditions. Their rules are much less rigorous, their material conditions are inferior, and they face some problems of indiscipline, delinquency and violence.

Young people recruit their friends in the social environment where they are inserted. Thus, the students of Montreuil, in the image of the population of that city, have friends of more diverse cultural backgrounds than those of Vincennes, whose environment is culturally and socially more homogeneous: two-thirds of the respondents in Providence are French of French parents against a fifth In the Jean Jaurès school.

The tendency to depreciate the other by the young people of the socially more favored classes that we found in Vincennes stresses the existing gap between the populations of the two cities. For example, Providence students consider it a privilege for foreigners to enjoy the same social rights as nationals, have few friends of foreign origin, show little interest in other cultures; their speeches reveal stereotypes; and are not available to social relations with the young people of the public schools of Montreuil, remaining in homogeneous groups more or less hermetic.

The population surveyed in Montreuil thinks, on the contrary, that French society does not provide an environment conducive to the integration of immigrants, in particular by racism and exclusion, particularly in the world of work.

The space of sociability is equally distinct: young people from the upper classes are preferably in private or closed and paid places, such as movie theaters, discos, private parties, while the most disadvantaged sections of the young population are limited often to public places such as the street and shopping centers (Augé, 1992). This way, populations that, despite their geographical proximity, avoid relationships between them, have their own body marks, their verbal and behavioral codes, and their sociability networks.

Sociability and love relationships

From the field research it can be seen that social space and the school environment guide perceptions and behaviors. The education provided by the family is based on the elaboration of the individuality of the young person as values and ways of thinking and doing are transmitted within them, but the peer group and the school environment where they spend most of their time form an element of identity construction and equally important behavioral orientation (Kindelberger, 2006).

Young people attach great importance to the way they are viewed by peers. The reassuring feeling of normality is built from the outward glances. Although they also seek originality in relation to the group, they manifest a need for conformity to the other elements of their network of sociability. The need to be in a group responds to social needs. Groups are a means of exchanging information and a way of communicating and being in relation to others. Adherence to the group responds to the need to feel integrated (Kindelberger, 2010). Failure to adhere to the implied peer group standards may even lead to exclusion (Woods, 1990). There is therefore a force that shapes and gives coherence to the groups of young people we have observed.

If we understand subculture as a convergence of behaviors, attitudes, values, beliefs, representations and experiences in the same social environment, we can consider that we are dealing with two "subcultures" (Hebdige, 2008). The young people interviewed in Montreuil create a subculture from an original symbiosis of the cultural diversity existing in the city and the school and from a social universe marked by precariousness. On the other hand, the young people enrolled in the private schools of Vincennes cultivate a subculture based on their cultural homogeneity and their social and scholastic belonging, the school functioning as an identifying element. The network of friends is the network par excellence of potential love and sexual partners, and these condition each other. Groups of friends are often the basis of romantic encounters, including night-time parties and organized parties at home. The formation of couples also responds to a harmony at the level of the beauty capital of the partners, which is a socially and culturally determined subjective quality. A couple considered aesthetically or socially unbalanced is subject to criticism by peers.

Another correlation is shown between the precocity of the entry into active sexuality and the widening of the circle of friends, which favors the occasions of encounters (Maillochon and Mogoutov, 1997). Thus, the young people of Montreuil, who have a sexual initiation earlier than those of Vincennes, also have wider networks of sociability.

A reciprocal control is exercised between the elements of the peer group and determines the nature of the peer group, giving it a unity and a group identity. This control determines the nature of the group of friends by giving it a unity and an identity that passes, as we have seen, through clothing, language, relational models, behaviors, etc. The place where one grows, the neighborhood where one lives, and the school that is frequented demarcate contours and limits of the perceptions, actions and relations of the individuals. The networks of sociability of the student groups observed are as differentiated as their social milieus.

Sociability networks draw particular styles and practices. It will be possible to find a young man from an Arab family and a young man from a French family who show more common points and more affinities than two children of French parents but from different social contexts. It is not so much the culture of origin that determines the behaviors, values ​​and perceptions of young people, but the social and institutional environment where they are inscribed, where they develop. The sociability that is built between subjects who grow up together, in the same neighborhood, in the same school, consolidates the ways of doing, saying, thinking and feeling, and draws the contours of the intimacy, love relationships and sexuality of its protagonists.

From interculturality to transculturality

The city of Montreuil is conducive to meeting cultures. The young people who are attending school are familiar with interculturality, as opposed to the youngsters at Vincennes. In the case of the populations observed, the greater or lesser cultural diversity lived in the city and in the school is reflected in their relations of sociability and love.

Interculturality is understood as a mode of interaction and interrelation that occurs through the contact of diverse cultures, as well as the changes or transformations that result from repeated or prolonged contacts (Giraud, 1995). Interculturality implies mutual recognition and respect, sharing, exchanges, interactions and positive and dynamic relations between different cultural groups within the same political unit, where there is room for affirming cultural identity as well as for opening up to other cultures (Clanet, 1990).

In the contexts studied, it can be observed that intercultural relations are promoted by the presence of multiculturalism, which characterizes the population of Montreuil. The young people of this city seem to be united in a community identity marked by both interculturality and social vulnerability, a phenomenon we have called transculturality. These young people create a cultural mix based on linguistic, clothing and behavioral elements, values ​​and attitudes, in a disadvantaged social context, which becomes an instrument of identity and community affirmation. Rap, as a contestation music and vector of the affirmation of the social identity of the young people of the suburbs, where African slang, French, Arabic words and African dialects mix and match, is a paradigmatic example of the expression of transculturality (Maia, 2010a, 2010b).

Transculturality results from an original cultural miscegenation, social identity, group solidarity, the creation of a sense of belonging to the cité and the search for social recognition in the plural territory that is the banlieue. Transculturality, an original mixture of cultures, expresses solidarity within the group and an identity in which the social context is the essential reference (Maia, 2009).

Conclusion

In reality, seduction, self-esteem, expression of affection, control of the body and its personal territory, the formation of socially and culturally mixed couples, the relationship with the risk of transmitting sexually transmitted infections, are adjusted by social learning. The construction of social identity is imprinted on the cultural and symbolic capital of each group (Bourdieu and Passeron, 1964) and is shown, for example, through language, school trajectory, networks of sociability and love choices (Maia, 2009).

The school environment functions as a factor of building sociability and insertion into a given social category. Being enrolled in a selective school, as in the case of private establishments, means attending individuals of high social status, learning how to behave because of belonging to a group that has its own codes, values, representations and behaviors. The selection of students, which goes through school results and economic capital, is rigorous, just like school rules. The school system, divided between public and private, thus amplifies the already existing difference between the rich and the poor, both in economic capital and in cultural and symbolic capital, and among culturally heterogeneous groups of young people. Hence the need to take the social and cultural levels as the main angles of analysis of young people's relational behaviors (Maia, 2009)

Culture is always at work in the communication between individuals and in the relations between them and the environment. In this sense, on the one hand, culture has always to be taken into account in the study of interpersonal relations and, on the other hand, the encounter between cultures is fundamental to the understanding of human existence (Lamarche, 2009).

Immigrant communities can become privileged bridges between cultures, provided that the necessary conditions for interculturality are met: that these communities are recognized, respected and integrated in society, that there is no racism or segregation, and that they are given the possibility to express of themselves (Berque, 1985; Vatz Laaroussi, 2015). French culture has an old humanist tradition that allows this opening of perspectives (Berque 1985). The intercultural relationship requires equal power between the actors and no one is devoured by the other. Thinking and acting in an intercultural framework destabilizes as much as it enriches (Chobeaux et al., 2005).

Never have cultures been in contact with each other. Globalization means not only globalization but also the circulation of goods, people and ideas, contacts, exchanges and mixtures, and the complexification of identities. The concept of interculturality has become fundamental for understanding the functioning of international relations as well as the relations between people in increasingly complex intercultural situations, in articulation with the political, economic, social and territorial dimensions of new cultural configurations (Clanet, 1986, 1990; Kerzil, 2002).

The concept of interculturalism implies meeting and sharing between cultures, respecting the fundamental originalities of each one. It simultaneously requires an openness to the world and a respect for the particularities of each culture. In order to carry out an intercultural education policy, it is therefore necessary to adapt school curricula towards greater cultural openness, tolerance, respect for the other and promotion of equality, and better training The culture in which pupils are trained can then be enriched by contact with other cultures from which the children of immigrants are vectors. The school must educate for citizenship, development, work, peace, human rights and intercultural. The intercultural dimension allows us to question the relationship with otherness, that is, with the other in what it has of universal and particular (Berque, 1985).

The "We," increasingly neglected in contemporary Western thought in favor of "I," would have much to gain from this greater openness to difference. We are moving from a societal model in which, in order to construct and give meaning to its existence, the individual should be included in his or her group of belonging, to a model in which the individual must constantly assert his autonomy and constitute himself as An "I", thus losing the solidarity. An alternative model, which we call transcultural, is proposed by these banlieue youths that we observe, like other social scientists (Avenel, 2006; Berque, 1985; Curie, 2006; Dubet, 1987; Duret 1996; Kindelberger 1996; Lepoutre, 1997), who find an anchor of their individual identities in their groups of belonging through an identity reconstruction constructed from materials made available by these groups, with all their richness in which the "I" is anchored in the "we ".

References

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XII. Dubet, F. (1987). La galère: jeunes en survie. Paris: Arthème Fayard.

XIII. Duret, P. (1996). Anthropologie de la fraternité dans les cités. Paris: Presses Universitaires de France.

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Children of the 21st Century. (Im)mobility and Autonomy

Catarina Sales Oliveira

Abstract

Recent studies on mobility in the West generally highlight its huge increase. This increase means not only bigger distances traveled but also the stretching of time spent in mobility especially in large metropolises. For the majority of citizens, mobility is a daily routine, integrating a lifestyle where the use of private car made possible a set of choices like a faraway place of residence, and accessing to places or services long distance from each other. The increasing mobility made people less dependent on proximity. This way of living is typical of active adult people but children are necessarily affected. In Portugal less than half of the children whose parents went to school on their own (walking or cycling) does that nowadays (Lopes, Cordovil and Neto, 2014) in a time when overweight is seriously affecting our population and is particularly worrying in childhood. In this paper departing from the mobility paradigm (Sheller and Urry, 2006) we propose a reflection about today’s children daily life, namely the likely consequences of auto mobilization from an early age and growing in a society where mobility has replaced proximity and the former is exalted simultaneously while right and value.

Keywords: children; youth: spatial mobility; autonomy; automobile

Introduction ​
The second half of the last century in Western society brought an increase in motorized mobility so intense and shaping contemporary lifestyles that several authors proposed it as an emergent paradigm (Urry; Sheller, Cresswell; Kauffman). In this proposal mobility is no longer just a way to reach an end (accessing places) usually analyzed from a more technical approach (choice and efficiency of the modal choice) to being analyzed in a way more comprehensive from a social sciences perspective that involves life choices and social relationships. In this turn the generalization of individual transport played a decisive role. It was the normalization of car’s daily use by the families that allowed the lengthening of the distances between home and work which in Portugal are growing since the 90s of last century. This trend also allowed other social changes: the modification of leisure and consumption habits, the reorganization of urban spaces and the increase in tourism practices (where the increase in aerial mobility has also played an important role).

In 1980 existed one car for every 4 Europeans, today the value is almost one car for every 2, children and elderly people included. In Portugal between 1985 and 1997, road traffic increased by 390%. In what concerns daily commuting in LMA (Lisbon metropolitan area) in the last two decades we assisted to a growth of 24% of individual transport use to in 1991 to 54% in 2011.

At the same time western society has changed in terms of risk perception (Beck, 1992; Flynn, Slovic e Mertz, 1994; Renn, 2008) and uncertainty and dependency representations (Bauman, 2007; Dean and Taylor-Gooby, 2014). The perception of risks must be understood within the social contexts.​
Regarding children several authors (Valentine, 1997; O'Brien at al, 2000; Barker, 2006) point out that the two factors more mentioned to justify car option for the transport of children are in the first place constraints of time and next security in the public space. In a public space that is increasingly urban and congested, children (who are fewer and occupy a more central place in the life of families) are moving more and more by car with their parents or other adults responsible for ensuring their security and access to increasingly protected places (Lopes, Cordovil and Neto, 2014).

Based on the analysis of these broad societal changes and data from some more specific studies on mobility and children in the Portuguese context we will reflect on the possible impacts of this generational change of lifestyle and values ​​of the 21st century’s children.​
(Auto) Mobility in Portugal

Compared to other European countries automobile mobility developed relatively late in Portugal. The conditions for its stabilization date back to the mid-twentieth century during the period of Estado Novo1, when not only basic road structures were created but also a complete "socio-technical system (...) accompanying/ aligned with the international standards and creating structures that would influence the development of this system during the second half of the twentieth century (...) a work that was appropriated by the discourse of the Estado Novo as a symbol of its achievement and of modernity "(Sousa, 2016: 22). The understanding of this process is particularly important to realize how in the rest of the century the massification of the private automobile is connected to a strongly rooted representation of well-being and success creating obstacles to the nowadays raising awareness and implementation of soft mobility.

Thus, while in other places road mobility is already declining3, in Portugal has grown exponentially in recent decades. Ownership of a first and even a second car by Portuguese families has maintained desirable and a common practice. In terms of territorial expression, the metropolitan areas are the places where more people move in public or collective transport, mainly due to the complexity of the traffic and parking costs. In the rest of the country the use of the private transport is even more marked than in those areas, where the modal shift was massive (Sales Oliveira, 2011) so we are speaking of percentages that overcome the 60% of private transport usage (Sales Oliveira and & Vaz 2014).

Taking metropolitan areas as case studies precisely for the existence of collective transport alternatives and looking at this issue beyond its objective dimension we find a behavioral and values ​​change. The protagonists of the modal shift towards the automobile tended to be men of certain social position, belonging to the so-called new middle classes of the late twentieth century.

"In this respect, the higher degree of physical mobility seems to be related to a differentiated social positioning within the so-called new middle classes.​
The inflexibility of public transport vis-à-vis the versatility of the car is not only concretely experienced but also socially conveyed in a complex scenario of micro coordination of tasks and time management (Castells et al., 2006), which contrasts individual mobility needs With the mobility options offered by public transport "(Oliveira, 2015: 148).

So today, despite the existence of an increasingly strong discourse on environment concerns and healthy lifestyles worldwide and also in Portugal, the car is paradoxically still considered something essential for the comfort and quality of life of families as well as for freedom of action and autonomy (Oliveira, 2011). In this context we ask how is the mobility of those who do not have direct access to a car?

Autonomous mobility of children in Portugal: some data​
"It is unthinkable to take my child to school without a car despite being in the same municipality, there are no transport." (Interviewed O. in Oliveira, 2011: 235).

Mobility studies show that families with children have a higher car use associating it with family care. The main responsible for children mobility is the mother persisting gender inequalities at this level (Oliveira, 2011). In LMA in families with dependents, 70% of women are responsible for the management of family mobility compared to 30% of men, and "children are rarely seen walking on and off the road" (Santos, 2017). This is due to the fact that, unlike men, one of the main reasons for women's use of the car is for personal / family reasons, and the car is symbolically associated with family comfort and quality of life (Oliveira, 2014).

Regarding the autonomous mobility of children in Portugal, a recent study noticed that only 21% of the children between the 3rd year and the 6th year of school - between 8 and 11 years old - and 45% of the children between the 6th and 10th grades - aged between 11 and 16 - move independently, ie without being accompanied by an adult, where 49% of them live at less than 1 km or less of the school. Less than one third of the children move by soft means - walking or cycling (Cordovil, Lopes and Neto, 2014). This study was representative for the Portuguese reality and did not find significant differences between the urban and the rural in what concerns distances traveled. On the other hand it found that the autonomy of rural children is higher because they have larger permission to move autonomously for others places other than school (friends' or family home, extra school activities, etc.).​
Reflection: unlearning to be autonomous in an immobile socialization process

Thus we can see for many of nowadays Portuguese children the distances between the anchor places of their lives have increased. Although many still continue to live relatively close to the school many others follow the needs and paths of their parents that tend to commute longer for work. At the same time family daily life became more complex with overload of tasks (Sales Oliveira, 2011; INE, 2012): for children of a medium and high socioeconomic level it is usual the practice of extracurricular activities representing a complex map of daily commuting within a city or even a region (Barker, 2006) and a tight agenda for different rhythms and schedules. In this sense in many children's daily lives mobility replaced proximity and being driven is an imperative for the child's participation in activities like sport or cultural practices that are considered by families as fundamental complements to their formal education.

At the same time auto-mobility as a system is far from being effectively challenged in Portugal and the car is still represented socially as a symbol of wealthy and its absence or nonuse perceived as an individual or family handicap.​
In this stage it is not possible to foresee the consequences of these trends. Still it is perceptible that a young age auto mobilization simultaneous of a withdraw of children from the streets has necessarily impacts on this generation representations and future lifestyles. In this respect, Gill (2007) points out that denying children interaction with risk in a controlled environment can lead to a "risk-adverse society" unable to manage day-to-day situations. For the Portuguese context Cordovil, Lopes and Neto (2014) have focused on the children’s loss of autonomy considering that learning to take responsibility for their own mobility was an important step in the process of growth that is being lost for the current generation.​
We argue that children who grow up in cars will tend to reproduce the automobile culture because childhood is a determinant phase of learning behavior models. At present, the intense practice of auto mobility is not only affecting citizens’ quality of life but also creates conditions for perpetuation of practices that compromise the objectives of sustainable development.

References

I. Barker, J. (2006). 'Are we there yet?': Exploring aspects of automobility in children's lives. (Tese de Doutoramento não editada ) London: Brunel University Human Geography.

II. Beck, U. (1992). Risk society. Towards a new modernity. London: Sage.

III. Cresswell, T. (2006). On the Move. Mobility in the Western World. New York, London: Routledge.

IV. Eurostat (2009). Panorama of Transport. European Communities.

V. Flynn, J., Slovic, P., & Mertz, C. K. (1994). Gender, race, and perception of environmental health risks. Risk analysis, 14(6), 1101-1108.

VI. Gill, T. (2007). No Fear: Growing Up in a Risk Averse Society. London: Calouste Gulbenkian Foundation.

VII. INE (2012). XV Recenseamento geral da população. Lisboa: Imprensa Casa da Moeda.

VIII. Kaufmann V, (2002). Re-thinking Mobility. Contemporary Sociology (Ashgate, Aldershot, Hants)

IX. Lopes, F. Cordovil, R. & Neto, C. (2014) Children's independent mobility in Portugal: Effects of urbanization degree and motorized modes of travel, Journal of Transport Geography, 41, 210-219.

X. O’brien, M., Jones, D., Sloan, D., & Rustin, M. (2000). Children's independent spatial mobility in the urban public realm. Childhood, 7(3), 257-277.

XI. Oliveira, C. S. S. (2011) Mobilidades e classes médias em contexto metropolitano. (Tese de Doutoramento não editada), ISCTE, Lisboa, Portugal.

XII. Oliveira, C. S. S. (2014). Still driven-Mobility patterns and gender roles in Portugal. CIES WP 185. Disponível em www.cies.iscte-iul.pt/np4/?newsId=453&fileName...Sales.pdf

XIII. Oliveira, C. S. S. (2015) (Auto) Mobilities and social identities in Portugal. in Sociologia, problemas e práticas, No. 77, (Jan-Apr), 137-151.

XIV. Oliveira, C. S. S. & Vaz, D. (2014) Mobilidade e quadro de vida contemporâneo: uma reflexão sobre os padrões portugueses de mobilidade espacial. In G. Baudin, G & D. Vaz, D. Transação territorial - Novas relações cidade-campo. V.N Famalicão: Húmus Editora.

XV. Renn, O. (2008). Risk governance: coping with uncertainty in a complex world. London: Earthscan.

XVI. Santos, S. (2017). Mobility and spatial planning in Lisbon Metropolitan Area. Finisterra, 52 (104), 57‑72.

XVII. Sheller, M., e Urry, J. (2006). The new mobilities paradigm. Environment and planning A, 38 (2), 207-226.

XVIII. Sousa, M. L. (2016) A Mobilidade Automóvel em Portugal, 1920-1950. Lisboa: Editora Chiado

Valentine, G. (1997). “Oh Yes I Can.”“Oh no you can't”: Children and parents' understandings of kids' competence to negotiate public space safely.

Chapter 9

Others

Adolescents’ Knowledge on Tobacco: a Question of Health Promotion

Silvana Souza Ferreira Pacheco da Cunha, Christina Cásar Praça Brasil; Raimunda Magalhães da Silva, Ana Maria Fontenelle Catrib

Post-Graduate Program in Collective Health, Fortaleza University, Brazil

José Manuel Peixoto Caldas, Mirna Albuquerque Frota

Faculty of Medicine of University of Porto, Portugal

Abstract

Smoking is a serious public health problem, causing thousands of deaths worldwide. In this context, there is a concern regarding adolescents, since many smokers begin the habit in this phase of life, being the target audience of the tobacco industry. This study aimed to verify the adolescents' knowledge about smoking. A qualitative study was carried out with 14 adolescents, participants of a social responsibility program promoted by a private University, in Fortaleza, Ceará, Brazil. A focus group on smoking-related issues was held in September 2016. Data were analyzed through content analysis in the thematic modality, and three categories emerged: "understanding smoking"; "dealing with people who smoke" and "coping strategies". The data were interpreted considering the literature on adolescence and smoking. Adolescents understand smoking as a dependency, associating it to the development of many diseases and recognizing the stigma that surrounds addiction. Participants deal with smokers assertively and know the bad effects of active and passive smoking. They point out smoking coping strategies that involve physical activity practice, healthy eating, and the need for specific treatment. The adolescents emphasized the need to accept the smoker without judgments or criticism, encouraging them to seek treatment. This research has shown that adolescents are well-informed and aware of the harm caused by smoking. It is recommended the development of new studies involving adolescents, so that they can help in the development of more effective and protective public policies focused on this population.

Keywords: Tobacco Use Disorder; Health Promotion; Adolescent

Introduction

Smoking is considered one of the main factors for the development of chronic diseases worldwide, so that six million smokers die every year and 600,000 are impacted by secondhand smoke. In this scenario, the World Health Organization (WHO) warns about the devastating effects of smoking (WHO, 2015).

The World Health Organization (2015) pointed out that in 2010 the prevalence of smokers of both genders was 22.1% of the world’s population and that the several regions of the world had considerable variations related to the prevalence of smokers. In this scenario, Europe is the region with the most smokers, with 29.6% of smokers, followed by the Western Pacific region, with 26.8% of that population; the Eastern Mediterranean region with 19.5%; the Americas, with 19.0%; Southeast Asia, with 18.2% and, finally, Africa, with 12.4% of smokers worldwide. It is estimated that by 2025 some of these regions will have increased tobacco consumption; however, even if there is such an increase in specific regions, there will be a decrease in the number of smokers worldwide, which could reach 18.9%.

Brazil belongs to the American continent, which consists of 19 countries, occupying the 11th position in relation to the number of smokers, with 17.6% of that population. Chile, in turn, has the highest percentage of smokers (40.1%); Barbados, in Central America, is the country with the lowest prevalence of smokers (7%) (WHO, 2015).

According to the Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Inquiry (VIGITEL), a large survey carried out in Brazil through a telephone survey with individuals older than 18 years of age residing in the Brazilian capitals, Brazil has a significant number of smokers (Brazil, 2017). The data showed that the frequency of adult smokers ranged from 3.7% in Fortaleza, state of Ceará and Macapá, state of Amapá to 9.5% in Curitiba, state of Paraná and Porto Alegre in the state of Rio Grande do Sul. The survey found that among the Brazilian capitals, São Paulo, state of São Paulo, was shown to be the one with the highest frequency of male smokers (12.2%) and Salvador, state of Bahia, with the lowest (4.9%). Porto Alegre was shown to be the capital with the highest frequency of female smokers (8.2%) and Fortaleza, the lowest (1.9%). This study also showed that, in relation to all Brazilian capitals, the frequency of adult smokers is 7.2%, with male smokers being more frequent (9.5%) than female ones (5.4%).

Aiming at fighting the worldwide tobacco epidemic, several countries have signed an international public health treaty called the Framework Convention on Tobacco Control (FCTC). Brazil, for its part, has taken a leading role in helping to prepare this document, which came into effect in February 2005. This global treaty covers measures related to the treatment of smokers, health warnings, prices, taxes, advertisement, among others, all of them with the intention of limiting the devastating consequences of smoking (Brazil, 2017b).

In this sense, other countries have been strengthening their anti-smoking policies aiming to limit the consequences of smoking. Italy, for instance, signed the FCTC in June 2003 and ratified it in July 2008 (WHO, 2005). According to the European Network for Smoking Prevention (2010), Italy and a few other countries are still not in full compliance with the FCTC principles, as they allow smoking rooms. The Italian law does not allow smoking in workplaces, restaurants and bars. However, smoking rooms are permitted, they necessarily have to be equipped with smoke exhausters. Places that do not comply with the law are liable to pay a fine of up to two thousand euros.

According to Croghan et al. (2011), Italy is a country that has boldly implemented anti-smoking laws, despite all the maneuvers from the tobacco industry. This country has been working on its laws aiming to verify their real effectiveness and to make the necessary adjustments, especially regarding the smoking rooms. Faced with these facts, Italy is seen as a country that demonstrates political will, being an example regarding the anti-smoking policies and actions.

Germany is a country that has several regulations regarding smoking bans in its different states. This is because the laws in that country came into effect at different times in 2008. Some states allow smoking in reserved places. But in others, such as Nordrhein-Westfalen or Thueringen, laws on smoking bans are not yet enforced. In 2007, there was a ban on smoking in taxis and public transportation. In 2010, the state of Saarland banned smoking in environments that host individuals (European Network for Smoking Prevention, 2010).

In Portugal, children under the age of 18 cannot buy tobacco products. The ban on smoking is effective in public places; however, in places that have adequate air ventilation system, the law allows cigarette smoking. Smokers and establishments that do not comply with the law are subject to fines. In Iceland, smoking is prohibited in any place intended for children and adolescents. Since 2007, bars, restaurants, discos, among others, have also validated the ban. In places of work, despite the ban, there is the possibility of smoking in places specifically designed for this purpose that have ventilation in accordance with the law (European Network for Smoking Prevention, 2010).

A study carried out in the United States inquired whether tobacco control policies are effective in reducing cigarette smoking by young adults. For this purpose, it was assessed whether laws related to cigarette smoke-free air, policy funding, and the price of tobacco products contributed to the reduction of the substance use among young adults. It was verified that both the funding of tobacco control policies in the country, as well as the laws related to cigarette smoke-free air were excellent strategies for reducing cigarette smoking among young adults (Farrelly et al., 2014).

Some countries have shown concern about stricter laws aimed to protect adolescents and young adults, as, according to the World Health Organization (2008), every day around 100 thousand young individuals try their first cigarette and more than half become regular tobacco users. Women and adolescents are the target audience of the tobacco industry, and this fact stimulates young individuals to start tobacco consumption early, since the onset of consumption occurs mainly during adolescence (Silva 2012a).

In line with adolescent and youth care in Brazil, the country has the National Health Promotion Policy, which was introduced in 2006 and has as main objectives promoting quality of life, and decreasing vulnerabilities and risk factors related to known health determinants. This policy has defined several high-priority actions, including the promotion of healthy eating, physical activity and cessation of tobacco and alcohol use, prevention of violence and promotion of a sustainable environment (Ramos, et al., 2014).

It is worth mentioning that, at present, there are no more media advertisements praising heroes or athletes who smoke; however, the encouragement of the tobacco industry shows that the launching of new products with attractive flavors, aromas, colors and packaging try to seduce the young consumer, even in the face of campaigns that portray negative images about smoking, drawing attention to its risks and effects. According to Giacomini Filho & Caprino (2006), the tobacco industry continues to carry out marketing strategies in a subliminal manner, even though, in Brazil, mass advertising of cigarettes has been prohibited since 2000. These strategies occur to keep the industrial branch profitable and the market goals achieved.

According to Silva (2012b), approximately 90% of adult smokers started smoking before the age of 20 and this initiation is mainly related to peer acceptance and non-perception of the consequences of smoking, which are not immediate. These factors do not allow the adolescent to worry about the damage caused by this behavior. Still according to the author, there are a range of other factors that motivate young individuals to start smoking, among which are influence of peers, challenge, imitation of parents' behavior and advertisement.

A study carried out by Pérez, Cárdenas & Martínez (2012) on the characterization of smoking in adolescents, showed that most of them smoked due to the influence of family members (82%) and that the family is responsible for setting the bad example. This same research also shows that friends who smoke also influence these adolescents to start smoking (24%). Martins & Seidl (2011) reinforce these findings by showing that peer influence was the most often mentioned reason related to the onset of cigarette smoking and that the influence of family members was the second most frequent one.

In view of the above, we believe that health promotion strategies aimed at adolescents must start from the deep knowledge of the perceptions this group has of the aspects that are intended to be addressed. Thus, to facilitate the creation and implementation of strategies to promote health and fight against smoking among adolescents, this study aimed to assess the adolescents' knowledge, personal relationships and coping strategies related to smoking.

Method

A qualitative study was carried out, as it allows the understanding of the investigated subjects’ perceptions (Minayo, 2014). According to Domenico & Sertório (2006), in qualitative studies, the meanings attributed to phenomena are the researcher’s primary concern, who will acquire and interpret the facts. The authors further argue that, in this type of research, the analysis of the obtained data will be compared with the available literature on the subject, when new interpretations and instructions may arise.

To select the participants, the researchers contacted the Vice-Rectory of Extension of a Private University, in Fortaleza, Ceará, Brazil, which is in charge of the Social Responsibility sector and offers continuing education courses to adolescents, young adults and adults. In September 2016, the Administrative Assistant course included 26 participants aged up to 24 years, who were invited to participate in the study, provided they met the following inclusion criteria: age between 10 and 19 years of age, to have an interest in the subject being discussed and availability to participate in data collection.

Among the students of the aforementioned course, 14 adolescents, 10 females and 4 males, were maintained in the sample, since the WHO establishes that adolescence is the period that comprehends from 10 to 19 years of age (World Health Organization, 1986). It should be noted that in this study, the age range of participants ranged from 15 to 18 years.

For the data collection, a focus group - FG (Trad, 2009) was carried out with questions related to smoking, during a meeting held in September 2016, during which the researcher presented the research objectives. Subsequently, an in-depth discussion was conducted, guided by the following questions: What is smoking for you? What are the effects of smoking on people's health? Do you know people who smoke? Do you have family members who smoke? Would you dare to smoke? Have you tried to help people who smoke?

The focus group was led by a moderator and two facilitators, who enabled the discussion and participation of all individuals. The duration of the FG was 2 hours and 30 minutes, and it was carried out in the University facilities that houses the course in which the participants are enrolled.

To preserve the participants' identities, they were coded by the letter "A", which means adolescent, followed by the numbers from 1 to 14. Thus, "A1" means “Adolescent 1” and so on.

The data collection was finalized based on the saturation principle, when the repetition of data was observed and no new facts emerged from the debate on the assessed subject. According to Salgado (2012), the sample size cannot be defined at the beginning of the research; only when saturation is reached, that is, when there are no new data coming from the focus groups.

The data were analyzed through content analysis in the thematic modality (Minayo, Deslandes & Gomes, 2009). In this sense, Bardin (2011) argues that this technique allows a more in-depth understanding of the explored issues, since it is capable of apprehending beyond what is being said. For this purpose, the following steps were followed: pre-analysis (material selection and continuous and thorough reading of the collected material); exploration of the material (material classification and understanding of the document so that categories are found); and treatment of the obtained results (deductions and interpretations) (Minayo, 2014).

The analysis allowed the creation of three themes: 1) understanding smoking; 2) dealing with people who smoke; And 3) coping strategies. These themes were interpreted through theoretical approaches that deal with smoking and adolescence.

It should be noted that all participants, after the initial invitation and the consequent agreement, signed the Free and Informed Consent Form (FICF). This study was approved under Opinion n. 1,508,603 by the Ethics Committee of Unifor and followed all the ethical principles of Resolution n. 466/12 of the National Health Council.

Results and Discussion

The results show that the participants are aged between 15 and 18 years, all of which are single, 13 in high school and only one in elementary school, having no professional activity. None of them used tobacco and/or tobacco products. Everyone understood the concept of smoking and stated they could help smokers with good advice and by demonstrating how smoking is harmful to one’s health. Six participants have friends and / or relatives who smoke.

Theme 1: Understanding smoking

In this theme, the adolescents voiced their understanding about smoking, by addressing the act of smoking, the diseases related to the habit and the existing prejudice against this act.

Regarding smoking, the definition given by A2 is as follows: “It is the act of routinely smoking cigarettes [...]”. This is a perception that can be found in several other reports given by the study participants, since it refers to a continuous and repetitive behavior associated with the smoking of cigarettes, referring to an idea of dependence. However, it is worth noting that not only cigarettes constitute a smoking tool for smokers, as there are other ways to consume tobacco.

From this perspective, although most adolescents believe that smoking is directly associated with the act of smoking cigarettes, others have a broader notion of this dependence, as can be seen in these reports: “[Smokers] are individuals who smoke any type of tobacco product, such as: cigarettes, hookah, pipe, etc.” (A1); “Smoking is the addiction that the smoker has... the smoker [emphasizes the word smoker], you know?” (A3); and “Smoking is the dependence on the substance [nicotine] ... found in some drugs such as cigarettes, hookah, among others...” (A5).

Adolescents know that smoking is an addiction and that the smoking behavior is associated with the dependence mainly on nicotine. According to Pupulim et al. (2015), nicotine acts on the brain reward system and is responsible for the chemical dependence of smoking, besides having an intrinsic association with environmental, genetic and biochemical factors. Silva (2012c) corroborates this idea by arguing that tobacco has several components and nicotine is responsible for the chemical dependence, due to the action of its nicotinic receptors. Nicotine acts on the Central Nervous System triggering feelings of pleasure, decreasing tension, reducing anxiety and improving memory, so that the person associates the act of smoking with the feeling of well-being.

When asked about the harm that smoking causes to the body, the adolescents emphasize the harm, not only those related to cancer, but also understand that several other diseases are caused in the context of this dependence, as the reports show: “It causes cancers, bad breath and other types of diseases.” (A1); “Smoking causes cancer among other diseases.” (A4) and “Cancer, aging, yellowing of teeth, low physical resistance.” (A11)

The idea of the damage that smoking causes to the body is defended by the Brazilian Society of Pulmonology and Phisiology (2010), which emphasizes that the number of deaths due to tobacco-related diseases is higher than those due to alcoholism, human immunodeficiency virus (HIV), tuberculosis, homicides, suicides and associated maternal causes. Thus, it can be perceived that the devastation caused by tobacco use is enormous, in addition to being responsible for one in ten deaths worldwide.

Another adolescent mentions the prejudice and social exclusion to which smokers are subjected, according to the statement of A2: “Sexual dysfunctions [referring to premature ejaculation], increased likelihood of developing cancer, exclusion from society... all of this can happen to the smoker. This is very sad, but you must know about these problems before you think about smoking...”

The prejudice and stigma directed at the smoker is very common in current society and people seem to have less and less tolerance for this type of addiction. Martins & Seidl (2011) point out that smoking is conceived as something unwelcome and has no social acceptance. However, it is believed that by being seen socially as a chronic disease and requiring specific care, the stigma surrounding smoking will be remedied and a new prism will be present as this behavior is seen from the perspective of the need for treatment and support.

One of the participants, in addition to emphasizing smoking as a dependence, also refers to the family disagreements that addiction causes, and made it clear that their understanding is not only related to organic damages, but also due to relational consequences: “Cigarette addiction causes a great deal ... dependence; family fights, if the family does not support it; cancer; shortness of breath; among other diseases.” (A12)

In fact, cigarette addiction causes discomfort to the smoker's entire family, especially as people understand the harm caused by this drug and usually become intolerant of its use. Not all people know how to deal with the situation of living with a smoker at home; they feel exposed to substances that are bad for their health and consider smoking as an aggression, a serious problem that needs support in several areas, including the family environment.

Theme 2: Dealing with smokers

In this theme, we identified the way adolescents behave towards individuals who smoke. Some reported not having smokers at home and others explained how they deal with the situation of living with smokers: “[...] I try to stay away from him [from the father who is a smoker], because I have allergies ... there is no other way, because he smokes all the time. I defend myself by keeping myself away. The bad thing is that it keeps us apart as father and daughter. I do not want to develop other diseases; the allergies are enough! This cigarette has already harmed us so much here at home.” (A1)

The report of A1 shows the anguish of a daughter that lives with a father who is a smoker and considers that the relational problems arise from the cigarette, since it keeps her apart from the loved one in the attempt to protect herself from other diseases that secondhand smoke can bring to her health.

Similarly, other adolescents say that they recognize the risks they face when they live close to smokers, making it clear that they understand the harm caused by secondhand smoking: “I encourage this person to stop smoking, by saying that cigarette smoking damages both his health and that of the people who live with him, including mine” (A2) and “I stay away [...] when he's smoking, I always say that the cigarette harms him and me.” (A5)

The WHO (2015) points out that secondhand smoke is very harmful to health, resulting in approximately 600,000 deaths per year worldwide. This shows that the consequences of tobacco use are harmful to all those around the person who uses the substance. This fact is relevant, since smokers very often do not even notice the damage caused to themselves, since cigarette smoking can take years to produce illnesses. However, the act of smoking, in addition to causing illness in the active smoker, also harms those living with him, as the passive smoker is also impacted by cigarette smoke and is at risk of developing severe illness.

According to the WHO (2009), second-hand smoke has a significant health impact on individuals exposed to cigarette smoke, which is a public health problem, since approximately 1/3 of adults are exposed to secondhand smoke worldwide, with consequences such as stroke, nasal irritation, problems in the reproductive system, among other diseases. Children also suffer the impact of smoke exposure, and can develop several types of diseases, including brain tumors, lymphomas, respiratory diseases, ear infections, developmental and behavior difficulties.

Another way adolescents express how they deal with smokers is to try to encourage them to stop smoking: “I keep away, I give him advice to stop smoking.” (A7) and “Helping a smoker [to stop smoking] is difficult because people often take pleasure in doing so. What I can do is to encourage the person to stop, telling them that it is harmful to their health and the health of the passive smoker [...]” (A12).

The words of A12 shows that the adolescent understands the difficulty the smoker faces to stop smoking and this fact is related to aspects of the organic and psychological dependence that tobacco causes, as well as the habits involved in the addictive behavior. Psychological dependence, which is one of the obstacles in the fight against addiction, is aligned with a web of feelings that support the act of smoking and, according to Echer and Barreto (2011), this dependence is interconnected with the way individuals deal with their feelings, whether good or bad. That is, the individuals face their daily difficulties and uncomfortable feelings by using the sensation of comfort provided by smoking.

Another adolescent declares that he deals with the smoker by talking about the harmful effects of smoking; however, he tries to get involved in the smoker’s rehabilitation, a point that is crucial in fighting addiction: “I try to help these people by showing the consequences of this type of habit and supporting their rehabilitation.” (A8). In this sense, Echer and Barreto (2011) argue that the support offered by the family, friends and colleagues is essential for the smoker to feel motivated to overcome the difficulties arising from smoking cessation. Echer and Barreto (2008: 447) also stress that “professionals and family and social groups can motivate, support and assist in this process, but the decision to change must be taken by the individual.”

Theme 3: Coping strategies

The coping strategies mentioned by adolescents for individuals to quit smoking go through several questions, namely: “Occupying the mind with physical activity is a way to get one’s attention away from cigarettes...” (A11). The adolescent points to sports practice as an excellent mechanism for coping with addiction, which is in line with what is proposed by Bordin et al. (2015). These authors argue that doing physical activity considerably contributes to relieving withdrawal symptoms, which are triggered after cessation of tobacco consumption.

One of the participants mentions that, in addition to issues related to the practice of physical activity, the smoker needs to reduce daily stress: “I would try to keep these individuals [the smokers] in a stress-free environment, where they would have access to sports and healthy eating.” (A2). This statement makes sense, as stressed and distressed people tend to smoke more, since the release of nicotine improves the overall mood (Silva, 2012c). Helping smokers to better cope with stress would be a way to help them fight addiction.

The suggestions of practicing sports and the need for a balanced and healthy diet go through the changes of habits that must be continuous in the lives of those who want to abandon the addiction. It is essential for the smokers to always be attentive to the changing needs of their routines, so they feel empowered and able to attain and maintain abstinence.

This change in daily living habits, including abstinence from tobacco use, results in several benefits. Pinto (2012) points out that the health benefits of smoking cessation may be immediate or late. The immediate ones occur within the first hours of consumption cessation, for instance: decrease in blood pressure, the improvement in the sense of smell and taste, among others. The benefits in the medium term occur from the tenth day until nine months after cessation and correspond mainly to the fact that withdrawal symptoms disappear between the second and fourth weeks after the cessation of the habit. The long-term benefits, however, occur after the first year of cessation. The risks of death and of developing some diseases are considerably reduced with the increase in the time of addiction cessation, such as the risk of premature death due to myocardial infarction, which decreases in the first year without consuming cigarettes.

Some adolescents are aware of the importance of seeking treatment to quit smoking, which they highlight and propose in their statements: “NGOs [Non-Governmental Organizations] should be created or treatment should be offered to smokers, so they can gradually stop smoking.” (A1).

In this sense, the search for treatment is a vital strategy for abstinence. Thus, the Ministry of Health proposes, through the National Program for Tobacco Control (PNCT), the treatment for this population, providing support manuals from the collection “Quitting Smoking without Mystery”, which provides subsidies for the cessation of the habit (Brazil, 2004). This treatment can occur both individually and in a group. In the latter form, the participants (10 to 15 per group) are initially submitted to four structured and weekly sessions. They are then submitted to treatment for one year (Brazil, 2001).

Although anti-smoking treatment is offered by the Brazilian Public Health System (SUS), the decision to stop smoking is for many individuals a path full of mishaps. Often, the smokers have ambiguous feelings about their addiction, so it is important to find out how the patient feels in relation to their change in behavior.

Prochaska & Diclemente (1982) developed a transtheoretical model of change in behavior that has five well-defined stages, which are described as follows:

Precontemplation: At this stage, the individual does not consider the possibility of change, that is, he does not perceive the need to change something, probably because he does not realize the damages associated with his behavior;

Contemplation: The individual can comprehend the existence of the problem, but has not yet initiated an action aimed at this demand;

Preparation: The individual has not yet undertaken actions to change his behavior, but the decision to do so already exists;

Action: the individual strives to perform the actions. At this stage, concrete steps are taken to actually change behavior;

Maintenance: actions are continuously promoted and strengthen the gains related to these same actions, so the patient maintains the change of behavior and prevents the relapse.

The transtheoretical model underlies the motivational interview, according to Miller and Rollnick (2001), which is a therapeutic, non-authoritarian approach that helps the subject to recognize and develop attitudes about their problems. It is a very effective mechanism in the treatment of addicts, as it helps to deal with the feelings of ambivalence, so often present in these individuals.

To know the smoker’s motivation in the difficult battle to stop smoking is crucial for the anti-smoking treatment, which was reported by one of the participants: “First, she must be willing to help herself and always seek treatment so that it can work. [cessation of addiction].” (A6). This idea is in line with a study by Echer & Barreto (2008) who argue that personal encouragement is one of the essential factors for smoking cessation.

In addition to the motivation to stop smoking, an adolescent refers to the smoker’s need to feel supported on this journey: “[...] support in a group, but without direct criticism and judgments, so as not to alienate the participant.” (A8). A study by Ismael (2007) confirms the adolescent's perception, in that it states that the approach to the smoker should be based on welcoming, positive and empathetic attitudes, without criticism or judgment; but rather motivation and sensibility towards the problem.

Additionally, A8's suggestion that the smoker's treatment be carried out in a group is very pertinent, since it allows the affective connection between the members and strengthens them in the search for abstinence. This helps those involved to feel safer and to be more assertive in pursuit of their objective. This idea is defended by Presman, Carneiro & Gigliotti (2005), stating that group treatment has many benefits, allowing members to discuss their difficulties and find effective ways to deal with risk factors, in addition to providing social support.

Based on several reports and suggestions from the study participants, it was verified that, in this context, the growth of social media can be a channel of information about smoking aimed at the young and adolescent public and, thus, a way to encourage someone to stop smoking. Thus, the creation of technological resources (applications, sites, YouTube channels, Instagram, for instance) aimed at combating smoking is a way to streamline the flow of data and information for decision making, contributing to the production of knowledge in networks and the expansion of health promotion actions. For that purpose, Pinto & Rocha (2016) consider Information and Communication Technology (ICT) as an innovative way of communication in health that qualifies the Unified Health System (SUS) in several areas.

Final Considerations

This study provided an opportunity to increase the knowledge of adolescents on smoking. Although none of the study adolescents is a smoker, they have a broad and satisfactory view of the habit of smoking. They understand that smoking is the act of smoking tobacco in different manners and that this behavior is supported by an addiction. They also mention the harm caused by smoking, as well as the development of diseases, the prejudice surrounding this type of behavior, as well as family and social disagreements that the addiction can cause.

Participants deal with smokers assertively, seeking to encourage smokers to stop smoking; however, as they are aware of the harmful effects of second-hand smoke, they try not to stay very long in the same environments as smokers. In the reports, the adolescents voiced the harm caused by cigarettes, for both the smoker and those with whom they live; however, they recognize the complexity of this addiction and the difficulty smokers have in discontinuing the consumption.

The adolescents point out that the practice of physical activity and healthy eating constitute ways of coping with addiction and alleviating withdrawal symptoms. They also emphasize the need for the smoker to undergo treatment, which must be carried out in a group, and with a good reception by the professionals, in addition to the support of family and friends.

In view of the above, we conclude the study participants are well informed about smoking, its risks and harms, showing that they are not “easy prey” for the tobacco industry, which continuously seeks new consumers. It is recommended that new studies be carried out, targeting adolescents, as they constitute the tobacco industry's target audience. We expect that the aforementioned results may help in the development of more effective and protective public policies aimed at this population.

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Health Promotion in School and Drug Use: Field Experience in a Municipality in Northeast Brazil

Christina César Praça Brasil, Raimunda Magalhães da Silva, Ana Maria Fontenelle Catrib

Post-Graduate Program in Collective Health, Fortaleza University, Brazil

Jarlideire Soares Freitas

Post-Graduate Program in Public Health, FederalUniversity

Cândido Norberto Bronzoni de Mattos

Post-Graduate Program in Collective Health, Vale do Rio dos Sinos, Brazil

Rogério Lessa Horta

Faculty of Medicine of Federal University of Pelotas, Brasil

Abstract

Drug consumption impacts on Brazilian children´s and adolescents´ health, thus, health promotion in the school environment becomes a way of coping with this problem. The objective of this study was to analyze field experiences and to explore preliminary data on health promotion and drug use in schools in the city of Fortaleza, Ceará, Brazil. Data collection took place from September 2015 to April 2016. The study was developed in partnership with Vale dos Sinos University and the University of Fortaleza. A total of 153 schools from State and Municipal teaching networks of the six education districts of Fortaleza were selected. A questionnaire was applied with the school managers and the researcher used a form to record the observation of the visited institutions. The project was approved by the Research Ethics Committee of Vale do Rio dos Sinos University. The results sought describing the field impressions, the promotion of health and the use of drugs. It was observed that the various health promotion actions are carried out in a precarious way in the public schools. Health promotion is developed in a punctual and discontinuous way, although some of the schools visited are part of the Health in School Program (PSE). Regarding drug use, it was possible to perceive a significant concern of the managers and educational actions directed to this theme. The research is being continues and its results will contribute to the construction of healthy educational environments, and the collection instrument can be replicated in other municipalities after its validation.

Key-Words: Health Promotion; Adolescent; Drugs; School Health

Introduction

Drug use by adolescents and children, whether they are licit ones or not, has been starting at increasingly earlier ages and this problem must be faced by an interdisciplinary team, involving all fields of this individual's life, so that new possibilities can be found (Andrade, de Micheli, & da Silva, 2014; Carlini et al., 2010).

From this perspective, the school becomes an important space, since it is a place of commercialization and consumption of alcohol and other drugs but, at the same time, also the place where information and prevention are disseminated (Barbosa, de Souza Pereira, & de Oliveira, 2014; Moreira, Lemos Vóvio, & De Micheli, 2015).

In Brazil, a study carried out with students from several cities in the country showed that 4% of this population had already used some type of drug, with the Northeast region showing the highest rate, reaching 7% of the assessed population (de Magalhães Câmara, Testa Tambellini, & Roselli-Cruz, 2010).

In the city of São Paulo, a study carried out with public and private schools showed that approximately 80% of schools had already identified students using or carrying some type of illicit or licit drug in the school environment, with cigarette smoking being the most commonly observed one (Dias Pereira, Tavares Paes, & Sanchez, 2016).

To prevent the use of licit and illicit drugs by students is a major challenge for educators and school administrators. Among the difficulties faced by them are: the insecurity experienced by professionals, who associate drugs to violence and trafficking, which makes them afraid to approach this population; the lack of knowledge and methods on how to approach the subject at school and, finally, the challenges related to the required infrastructure at school to deal with the problem (Matias de Santiago, Pacheco Rodrigues, Dias de Oliveira Junior, & Magalhães Moreira, 2012; Moreira et al., 2015).

The consumption of alcohol and other drugs has an impact on the health of Brazilian children and adolescents and, within this context, health promotion in the school environment becomes a way of coping with this problem and a means of protecting this population, being recognized as an important strategy linking health and education with a common objective (Moura, Monteiro, & Freitas, 2016).

Considering these facts, the aim of this study was to analyze field experiences and explore preliminary data on health promotion and drug use in schools in the municipality of Fortaleza, state of Ceará, Brazil.

Method

This is the report of an experience carried out by researchers in the city of Fortaleza, Ceará, Brazil, from September 2015 to April 2016. This study was carried out during the validation of a questionnaire with managers of municipal and state public schools, aiming to evaluate health promotion in the school environment and its association with drug use by the students.

The present study was carried out through a partnership between Universidade Vale dos Sinos, in the municipality of São Leopoldo, Rio Grande do Sul, Brazil, through the conception of the project and the creation of the tool used; and Universidade de Fortaleza, Ceará, Brazil, responsible for the validation stage of the tool in local schools.

For the sample, 153 schools of the state and municipal school network of the six regional subdivisions of the city of Fortaleza were selected. Initially, permission to carry out the research was requested through a letter of consent, sent to the Municipal and State Education Secretariats and, upon entering the study field, the school managers were also asked to sign a letter of agreement ensuring the research would be carried out in each unit. After these documents were obtained, data was collected.

The data collection tool occurred at two different moments and the collection lasted an average of one hour, depending on the interviewee’s availability.

Initially, the manager of each school answered a questionnaire that comprised the initial characterization of the institution (maximum number of students per classroom, average class size in meters, outdoor leisure area and number of classrooms) followed by 40 objective questions, which dealt with the conditions and actions taken at the schools in relation to their students’ health promotion.

At the second moment, the researcher carried out an observation visit at the school facilities accompanied by an employee. On this occasion, the researcher filled out a form containing 20 objective questions about the structural and organizational aspects of the school, which included: type of food available to students; presence of posters, pamphlets and other forms of communication directed to students on aspects related to sexual and reproductive health, use of alcohol and drugs, among others; maintenance and cleaning conditions of bathrooms, courts, cafeteria; accessibility conditions, illumination, ventilation, security; furniture maintenance; in addition to the classification of the environment as adequate or not for children and adolescents.

It is noteworthy that all the questions at the first moment were documented in writing and the managers’ statements were recorded, once it was realized that the detailed testimonies would be relevant for the study development and the report of the experience. Even at the second moment, the statements of the employees who accompanied the researchers during the environment assessment were also documented in writing and recorded, due to the complementarity of facts they brought to the global context that was being experienced at the time, offering connections and facilitating the understanding of the context and the significance of the observations.

The project was submitted to and approved by the Research Ethics Committee of Universidade do Vale do Rio dos Sinos (Process n. 025/2013).

Results and Discussion - starting the field research

The municipality of Fortaleza is divided into six education districts and as schools were selected from all regions, aiming to avoid any kind of bias that would mask the reality of the municipality, access difficulties related to distance and insecurity, especially in the risk areas, constituted the background of some of the evaluated schools. To ensure a more accurate picture of the reality of the municipality, it was crucial to go everywhere to understand the differences between the regions and how health promotion was taking place, so we could consider their specific characteristics.

For the study to be carried out in a timely manner, a team of 15 volunteers was recruited, who received financial aid to apply the questionnaires. There was also a data collection coordinator, who sought to establish the best route and to ensure that these researchers could safely perform the field work. Still, there were moments of tension for the team, who had to use maneuvers to guarantee their safety and finish applying all the questionnaires.

The schools reflect the community where they are located. It was observed that those located in regions with high levels of violence and social problems directly reflect the undesirable environmental conditions on their infrastructure, since they have higher walls, are more enclosed inside iron gates and have little access to the visualization of external areas. In more violent communities, the representation of violence in schools is more evident; however, there are different forms of violence in these spaces, which directly influence the quality of education offered at the schools (Rosa, 2013).

Initially, it had been predicted that contact with the school manager should be scheduled through telephone calls, whose contact numbers had been provided by the municipal and state education secretariats. In practice, that did not happen, because the contact numbers were not always correct or the phones were not working. In some cases, despite repeated calls, the telephone was never answered. In those cases where contact was established by telephone, it was observed that some school administrators were unwilling to receive the researchers’ visit, setting very distant dates for the meeting to take place or simply refusing to grant the information.

Therefore, in most schools, the researchers had to make their first contact in person, during which they showed the letter of agreement from their respective education secretariats and, thus, they could finally be received. It is noteworthy that the researchers were welcomed by the managers in most schools, but some were harsh and suspicious of the visit, even refusing to participate in the study.

In Brazil, there are few studies that address educational managers, with teachers and students being the main subjects in studies taking place in the school scenario. This results on lack of data on the number of school managers in basic education in the country (Vieira & Vidal, 2014).

School management staff is chosen in a democratic manner, with the principal being initially submitted to a selection based on technical competence and then to a direct election. After being elected, he or she will choose the coordination team that will participate in the management (Naspolini, 2001; Scott, da Silva Machado, do Vale Horta, & Machado, 2014). These managers are given a position of trust that can be taken away if they do something that displeases the political management. This causes the fear and insecurity when answering surveys in their workplace, especially when these surveys have the assessment as the focus. This is especially challenging when the manager does not have a statutory employment contract.

Field Impressions

When entering the research field, the first relevant factor observed concerns the difference of reality in each school visited. In general, state schools have a better infrastructure than municipal ones, with better equipped classrooms, even including air-conditioned rooms in some of them; the presence of more laboratories and more welcoming environments.

However, regarding violence, the disagreements between teachers and students, drug trafficking and consumption, the state schools had more frequent reports of conflicts during data collection. This is evidenced by the fact that the state schools include high school students, a population constituted by of adolescents and young individuals. This fact shows that, among other things, the students’ age group directly affects this reality. Studies indicate that the use of illicit drugs increases with age and this may be related to greater problems with violence in state schools, which, considering their education priority, receive the older age group (Horta et al., 2014).

The responsibility for elementary education in Brazil was divided between the Federal, State and Municipal governments. The municipality is responsible for early childhood education and elementary education, aimed at the population aged from 4 to 14 years. The state government is responsible to ensure high school education as a priority and to collaborate with municipalities with by also providing elementary education (Federal, 1996). This organization, in which the levels of education are divided by the three levels of government, helps to understand these differences between municipal and state schools. In addition to the fact that the state is responsible for the education of older individuals, it also has greater financial resources for investments.

The schools also show differences according to where they are located. It was possible to perceive that the ones located in the outskirts of the city showed different infrastructure and maintenance when compared those located in richer areas, be they state or municipal schools. In this sense, it is inevitable to consider that factors external to the school environment, such as violence, quality of life, income, public health, among others, directly influence the quality of the school and the education offered, as well as affecting how health promotion is developed in these spaces (Gramani, 2017).

Within this context, we observed schools with excellent quality standard, well-maintained structures, located in the most well off areas of the city. Most of these schools receive students from all neighborhoods; however, to enroll in one of them, in addition to being difficult, requires students to have excelled in their previous school.

Another situation was that of schools managed by a military body (firefighters or the military police), which also have a different type of management and financial support, with a high standard of quality, organization and infrastructure in relation to those that are directly associated with the municipal or state governments. These schools are primarily intended for relatives of military personnel or those who are approved in the entrance examinations.

Trade schools, which are the responsibility of the state, also showed a different reality when compared to most of the assessed schools. Located in several areas of the municipality, they have a high-quality structure and offer, in addition to high school, vocational education, guaranteeing to their students a technical education upon completion of elementary school. In addition to being difficult to enter, these schools only accept students who perform well in elementary education.

Among the top ten best performing public schools in Enem, the Brazilian Scholastic Assessment Test, two were military schools, seven were part of a trade school project and one was a full-time establishment, although it was not a trade school. In a study carried out with five of these schools, factors such as the desire to learn, collective self-discipline, longer term, being full-time, offer of internship, participatory management centers, and special incentive for teachers were some of the aspects found as distinguishing factors (Haguette, Pessoa, & Vidal, 2016).

It is worth mentioning, however, that the average scores at the Enem, even in the best public schools, are still worse than the average ones for the best private schools. This demonstrates that public education still has much to improve regarding its level of education and indicates that the education in the state of Ceará and in Brazil is influenced by matters of social class (Haguette et al., 2016). This question needs to be addressed so that the opportunities offered to Brazilian students will be equivalent, aiming to offer high-quality education regardless of ethnicity, skin color and social class.

Health Promotion and Drug Use

Regarding the questionnaire application, the statements were recorded after the managers gave their consent. When the questions were asked, the answers showed to be meaningful and important testimonies to understand the association between health promotion and drug use in the school scenario. These reports often extrapolated the dimension of quantitative questions and brought great subjective meanings.

These statements were crucial for us to understand the dynamics of each school and, based on them, a qualitative study started to be developed by the local researchers.

It was also observed that health promotion was carried out irregularly and sporadically in most of the assessed schools, being related to science, physical education, and biology classes or some other discipline associated with health issues.

The partnerships established between schools and public and private institutions and the community, aiming to promote students' health-related actions, was a reality and a necessity indicated by the managers. The Basic Health Units located near the schools were mentioned as the main partners in these activities; however, it was observed that most of the developed actions are sporadic ones, such as vaccination and oral brushing campaigns.

Another group that approaches the school as a health promoter are firefighters and the military police, who have their own projects of lectures in schools to warn mainly against the drug issue and its impact on the health of children and adolescents. Universities were also mentioned by the schools as their partners in health promotion. In those schools where this partnership existed, there was a greater concern with health promotion and more continuous and committed actions.

However, we did not observe in most schools, their own projects aimed at their students’ health promotion. Some managers reported that they took the opportunity to discuss health-related issues at school fairs and events, which occurs at least once every year. In this context, it was observed that, although half of the selected schools were part of the School Health Program (PSE), of which objective is the permanent partnership between health and education, aiming at promoting a better quality of life and which core is the interdisciplinarity (Costa, 2014); the schools have not yet fully absorbed this public policy, since the PSE proposals are still far from being properly implemented.

As can be demonstrated in recent studies, despite the unquestionable importance of the PSE, its credibility is low and there is a lack of communication between the sectors, highlighting the role of school managers in carrying out more effective actions to promote health in the school environment and improve the intersectoral relations (Farias, Franco de Sá, Figueiredo, & Menezes Filho, 2016).

Regarding drug use, managers reported this is considered a primary subject at school, declaring that it is treated more broadly than other health-related topics. In several schools, this subject is continually addressed in lectures, talks, school fairs and other school events. From another viewpoint, it was also observed that, although necessary and urgent, the subject shows a certain saturation on the part of the students, who are constantly approached to talk about drugs. Considering the known figures about the use of licit and illicit substances in the schools, it is possible to observe that, although it is a recurring theme, it does not lead to change in behaviors.

In addition to being a place for health promotion, the school is also a place where certain behaviors can be observed, which will identify whether the child or adolescent is starting to have contact with illicit drugs, based on the observation of unjustified absences and conflicting family relationships, so that educators and managers, in addition to family members, can establish monitoring and intervention actions (Horta et al., 2014). These actions are very important in the context of health promotion, since the school is a strong ally of society in the fight against violence and the development of habits that are harmful to health and citizenship.

Final Considerations

Based on this experience it was possible to understand how education and health are dealing with health promotion in schools. Although it is a complex and necessary subject, the issue of drug use by adolescents still requires a more effective approach to attain behavior changes.

The reality found in the public schools of the assessed municipality was very diverse. The closer they were located to the outskirts of the municipality, the worse the conditions offered to students and teachers, and, in these cases, health promotion is overlooked, considering the enormous challenge of promoting education in these spaces.

The partnership between health and education, even with the SHP, does not occur in a systematic way and health promotion in these spaces is still carried out in an irregular manner. This study did not assess the families’ participation in the health promotion process, which constitutes a limitation.

The data obtained at this research are being analyzed and the results will contribute to the construction of healthier educational environments, and the data collection tool can be used in other municipalities to assess health promotion and its association with drug use.

References

Andrade, A. L. M., de Micheli, D., & da Silva, E. A. (2014). Neurociências do abuso de drogas em adolescentes. Prevenção ao uso de álcool e outras drogas no contexto escolar, 25.

Barbosa, A. J. G., de Souza Pereira, C. E., & de Oliveira, J. C. (2014). Prevenção escolar ao uso de drogas por adolescentes: intervenções que funcionam. Prevenção ao uso de álcool e outras drogas no contexto escolar, 49.

Carlini, E., Noto, A., Sanchez, Z. M., Carlini, C., Locatelli, D., Abeid, L., & Moura, Y. d. (2010). VI Levantamento nacional sobre o consumo de drogas psicotrópicas entre estudantes do ensino fundamental e médio das redes pública e privada de ensino nas 27 capitais brasileiras–2010. Brasília: SENAD, 29.

Costa, J. C. (2014). Reflexões sobre sexualidade, corpo e poder no ambiente escolar a partir do Programa Saúde na Escola.

de Magalhães Câmara, M., Testa Tambellini, A., & Roselli-Cruz, A. (2010). Trabalho, abuso de drogas e os aparelhos ideológicos de Estado: um estudo com alunos do Ensino Médio e Fundamental. Physis-Revista de Saúde Coletiva, 20(1).

Dias Pereira, A. P., Tavares Paes, Â., & Sanchez, Z. M. (2016). Fatores associados à implantação de programas de prevenção ao uso de drogas nas escolas. Revista de Saúde Pública, 50.

Farias, I. C. V. d., Franco de Sá, R. M. P., Figueiredo, N., & Menezes Filho, A. (2016). Análise da Intersetorialidade no Programa Saúde na Escola. Revista Brasileira de Educação Médica, 40, 261-267.

Federal, S. (1996). Lei de Diretrizes e Bases da Educação Nacional. Brasília: MEC.

Gramani, M. C. (2017). Análise dos determinantes de eficiência educacional do estado do Ceará. Ensaio: Avaliação e Políticas Públicas em Educação, 25, 507-526.

Haguette, A., Pessoa, M. K. M., & Vidal, E. M. (2016). Dez escolas, dois padrões de qualidade. Uma pesquisa em dez escolas públicas de Ensino Médio do Estado do Ceará. Ensaio: Avaliação e Políticas Públicas em Educação, 24(92), 609-636.

Horta, R. L., Horta, B. L., Costa, A. W. N. d., Prado, R. R. d., Oliveira-Campos, M., & Malta, D. C. (2014). Lifetime use of illicit drugs and associated factors among Brazilian schoolchildren, National Adolescent School-based Health Survey (PeNSE 2012). Revista Brasileira de Epidemiologia, 17, 31-45.

Matias de Santiago, L., Pacheco Rodrigues, M. T., Dias de Oliveira Junior, A., & Magalhães Moreira, T. M. (2012). Implantação do Programa Saúde na escola em Fortaleza-CE: atuação de equipe da Estratégia Saúde da Família. Revista Brasileira de Enfermagem, 65(6).

Moreira, A., Lemos Vóvio, C., & De Micheli, D. (2015). Prevenção ao consumo abusivo de drogas na escola: desafios e possibilidades para a atuação do educador. Educação e Pesquisa, 41(1).

Moura, N. A., Monteiro, A. R. M., & Freitas, R. J. M. (2016). Adolescentes usuários de drogas (i) lícitas e práticas de violência. Revista de enfermagem UFPE on line-ISSN: 1981-8963, 10(5), 1685-1693.

Naspolini, A. (2001). A reforma da educação básica no Ceará. Estudos Avancados, 15(42), 169-186.

Rosa, M. J. A. (2013). Violência no ambiente escolar: refletindo sobre as consequências para o processo ensino aprendizagem. Revista Fórum Identidades.

Scott, V. d. S. P., da Silva Machado, M. C., do Vale Horta, P. M., & Machado, C. S. (2014). A política de seleção de gestores escolares da rede municipal de educação de Belo Horizonte na perspectiva de modernização da gestão pública. Revista Pesquisa e Debate em Educação, 3(2).

Vieira, S. L., & Vidal, E. M. (2014). Perfil e formação de gestores escolares no Brasil. In: Dialogia.

Occupational Therapy: Children and Youth Life Cycle

Vanda Cristina Barrocas Varela Pedrosa

ACES (Lezíria), ESSLEI Lezíria

Abstract

Introduction: The child and family with special needs and questions need follow-up, supervision and greater attention to develop skills, abilities and greater autonomy. The importance of the Occupational Therapist (OT) integrated in a team in the context of early intervention in childhood and in school age is already recognized by the community, which is the target of many studies (still few) in the community.

Objectives: The purpose of the compilation is to reflect on the follow-up practices of OT in the first stage of the life cycle in Primary Health Care, facilitating future interventions.

Method: The reading of data refers to a period of 17 hours, corresponding to approximately half of the hours an OT works weekly in the Primary Health Care, 35 hours. The results are numerical/descriptive, have a non-experimental, retrospective, longitudinal nature, were carried out between March 2005 and March 2016, with an interruption in 2013. The service does not have a validated information system. Data were retrieved from excel sheets.

Results: A total of 253 different children/young people with at least 1h or more of care were assisted, ranging from 0 months to 18 years old: 74.3% between 1 month and 6 years old and 25.7% between 7 and 12 years old, 58.1% male and 41.9% female. Requests came from the community and the family also participated in the process of signaling.

Conclusion: Children were mostly referred at early ages, due to Communication and Relationship Disturbance and difficulties in social interaction without known etiology. The monitoring of OT is indispensable in the Community. Care without assistance is also a necessity.

Keywords: Occupational Therapy; Primary Health Care; Early Intervention in Childhood

Framework

Clearly, health begins at home within the family, in the community and in society.

For this reason, the role of the health professional is to help find out what makes most sense for a child and his or her family, since all parents do a great job, and all contexts have potential to provide children with experience. 1, 8

Most problematic situations focus primarily on Primary Health Care, highlighting the importance of this first line of action in screening, evaluation, intervention and guidance, making the diagnosis of psychopathological situations of risk and the timely implementation of preventive and therapeutic strategies a priority. It refers to places with the necessary resources to intervene in the community, not only for the knowledge of families and their life trajectory, but also for their understanding of needs and resources. ², 12

It is in this context that the intervention of the OT in the Community develops services, using a customer-centered approach (family, caregivers, teachers, other significant people), that are a true protective factor in the promotion of Health and participation in occupation, involving each person with respect, as well as their desires and priorities, in an intervention that is intended to be collaborative. It is an intervention based on life cycle and settings, which facilitates the integration of health problems from different age groups and gender in the different social roles that the citizen takes over throughout life. In other words, it is a set of needs and opportunities for lifelong intervention highlighted at such special times such as birth, death, entering school, first job, marriage, divorce, retirement, or other. 3, 4, 5, 6

And it is precisely at birth and during the development of early childhood that one has realized what happened during 10 years of professional activity in a public service in a Community Care Unit, between the ages of 0 and 18 years, Community Care Unit of Cartaxo (CCCU) in the Occupational Therapy service.

As the intervention with children and young people in services is divided mainly between the precocious, made preferably from 0 to 6 years, and the one in the next age group, from 6 to 18 years, it is important to understand where the referrals received and the real intervention of the OT were centered, namely which children/young people had at least 1 hour or more of intervention in the service. 1,5,6,7,12

The purpose of the compilation is to reflect on the follow-up/intervention practices used by OT in the first stage of the person's life cycle in Primary Health Care, making suggestions and improvements that should be considered in future interventions. A practice which, especially between 0 and 6 years of age, should be based on an articulation basis for: early detection of risk situations and timely intervention; greater effectiveness of intervention in complex situations with a strong social/community dimension; implementation of programs of primary prevention, early intervention and training. 2, 12

Data reading always considers the fact that the OT professional reports during the hours of service in Primary Health Care, spending approximately 17 hours out of 35 hours per week. The results are numerical/descriptive, depending on what was referred versus treated by the OT. They are non-experimental, retrospective (referring to past periods), extensive (over 10 years) and cover a period between March 2005 and March 2016, with an interruption in 2013. Since the service does not have a validated information system, data were taken from completed excel sheets over 10 years.

Results

A total of 253 different children/young people were referred to the CCCU OT service.

They were assisted at least during 1h or more, and were between 0 months and 18 years inclusive project. Among the children/young people referred and assisted, 74.3% were between 1 month and 6 years old and 25.7% were between 7 and 12 years old inclusive. In relation to gender, 58.1% are male and 41.9% female.

In Early Intervention in Childhood (EIC), 59.8% of the children are male and 40.2% female.

In School Health (SH), children/young people are mostly male, 53.2% and the total of situations of the feminine gender was 46.8%.

Many children moved between EIC and SH projects due to age factor and not by any other criteria.

The signaling/requests came from at least 1 source in the community (some came from 2 or more), especially due to the concern they caused to the community and/or family at the moment.

Among the referrals, 28% came from Integrated Early Intervention Team meetings, 19.4% from the Community Care Unit, 19% from the Family Doctors of the Family Health Units, 14% from the family, 11.5% from the specialist of the District Hospitals (usually via development appointments), 5.4% from School Groups and 2.9% from Children and Youth Protection Commissions.7,12

The appointments occurred in an average of once a week, regardless of age, which is supported by the literature that indicates that the intervention of OT with situations of Special Educational Needs in school age, is performed in 77.5% of appointments, especially once a week. 1

The weekly sessions were usually held for 1 hour, mainly in the Health Center or in the Early Stimulation Room. It lasted up to 1.30 hours in the community, corroborating the literature that indicates between 30 and 60 minutes, in an average of 44.4 minutes. 5, 7

Considering the place, 59.6% were assisted in community structures, 29.9% in health units and 10.5% at home. This does not corroborate what literature indicates, which is that 92.5% of OT professionals preferably intervene in an individual room. 1,5,6,7

Community structures are nannies, nurseries, kindergartens, early stimulation rooms within the community - all the structures beyond the physical structure of the Health Center. Domicile is the official residence of the child/family during service.

The presence of the family is confirmed in all the diligences carried out, except when the team meets to make a report for a specific appointment. Regarding care without assistance, the literature describes that the most frequent are "parent meetings", "team meetings" and "teacher meetings", with a utilization rate of 53.1%, 53.1% and 50%, respectively. Less frequent were the "interdisciplinary meetings", "appointments and technical advice" and the "analysis and quotation of evaluation instruments", with utilization rates of 21.9%, 21.9% and 15.6%, respectively. Based on the study it was inferred that the time spent out of the appointments complies with the indicated one, since the "team meetings" were used 64.9% of the times: approximately 47.5% in EIC and 17.4% in SH. 31.6% of the hours were also spent in "family" and "school" meetings, developing "records" and making "telephone contacts". Less significant was the "appointment follow-up", with a utilization rate of 3.5%. 7, 8

Regarding the type of follow-up performed by OT, the literature indicates that in 47.5% of the situations it is assisted individually and in 52.5% in conjunction (group and individual). Nevertheless, there were a few weeks in which the same child/family was assisted twice: 1 appointment in the Health Center and 1 appointment in the context of Kindergarten, due to collaboration needs between the rest of the work team and the family. This knowledge goes along with the usual duration of each intervention. No cumulative intervention was found (individual and group). Based on the experience, it was concluded that 93.1% of the all the interventions performed in children between 0 to 12 years old were made individually. The intervention lasted at least 1 hour (single) or more. Only 6.9% of the situations were assisted in a group. The focus was conducting only individual interventions or only interventions in group. This situation is analyzed given the difficulty of defining hours of care to each child/family, so the ones who need it were privileged, having at least 1 hour a week, so that a greater number of children could benefit from the service, leaving as few situations as possible without care. 2, 12

Given these data, it is important to know what situations are met, both within the EIC and the SH, and to understand the particularities of each age group.

EIC is developed through the National System of Early Intervention (NSEI) of the coordinated action of the Ministries of Solidarity and Social Security, Health and Education and Science, with the involvement of families and the community. According to the literature, the pathology almost universally taken care in school age by the OT is a group of autism spectrum disorders, with a percentage of 97.5. 7

The national referral form allowed us to know that situations were identified (and that they were assisted at least once) and distributed in 4 large groups: changes in structures and body functions due to development delays without known etiology, 49.2% of cases assisted; changes in structures and body functions due to development delays caused by specific conditions, with 35.4% of situations; serious risk of developmental delays due to exposure to biological risk factors, with 6.9%; and sensory learning/integration difficulties in the preschool phase (4 to 6 years), with 8.5% of situations.

This means that among the children referenced by the EIC to the OT, which were answered (1 or more times) between 2005 and 2016, 84.6% presented changes in the Structures and Functions of the Body, limiting "normal" development and the participation in normal activities, considering their own developmental frameworks for their age and social context, eligible for NSEI, whether for well-defined reasons or not. 5, 7, 8

This early referral (it usually happens before 2 years of age) indicates that the early recognition of neurodevelopmental problems is beginning to be promoted. It is a clear responsibility of all primary care doctors conducting children's health appointments, including ambulatory pediatricians, which detect risk factors, socially integrated in its cultural space. Even so, slight changes are not easy to detect, although they always offer some concerns because they denote a neurological, sensory or, rarely, environmental dysfunction. The key screening age for global neurodevelopment problems match the routine appointments at 9, 18, and 24 or 30 months. 5,7,8, 14

These are very early concerns by the way they are addressed. The care principle focuses entirely on caregivers, giving them the opportunity to express their suspicions and questions because, until proven otherwise, their questions have been highly valued. Besides, observing the behavior of the child since the beginning until the end of the appointment also represented an opportunity to reveal his or her abilities and skills. This kind of evaluation must always be made discreetly. 8 In the first 2 years of life, the gestational age of the child must be considered. 14

The situations with no known etiology represent 49.2% of data. On average, 5 children per year with no known etiology were identified in the TO service. 7, 14

The group was divided in 2: social and adaptive difficulties, 66.6%, and physical and motor difficulties, 33.4%.

The first group includes 59 children referred without known etiology and with concerns in relation to social and adaptive competences (before being 2 years old), 36 of which are boys and 23 are girls. Many of these children (despite parents and doctors concerns in relation to social and adaptive competences), have not a diagnosis confirmation of a possible communication and relationship disturbance, having carried out a regular family, preschool and school journey.

Since neurodevelopment is a very natural and dynamic process, with individual differences that happens as a result of outbreaks at a non-consistent speed, many of these 59 children needed their "own time" and extra directions were given to the family, so that development would be harmonious, calm and without major worries. 7,8

The fact that 52 children with changes in communication and in the relationship at an early age (42 children before 4 years of age) were admitted suggests that the OT service goes along with the observance of early diagnosis. In other words, a large phenotypic variability, a clinical spectrum that is characterized by difficulties in social interaction, by limitation in verbal and non-verbal communication and also by the presence of rigid behavior with repetitive and limited interests, signaled to the OT service as changes in relation and in communication, which are the aspects that offer greater concern to parents and the medical community. It is a chronic pathology that, in most cases, has serious implications for social integration in adult life. In Portugal this represents an estimated prevalence of 1 case out of 1000 school age children.6

All other situations arose in the global motor functions domain, more specifically in physical and motor skills, with special focus on 2 years old children who couldn't walk or walked on tiptoes. Main concerns are with the introduction of shoes, the use or not of baby walkers-in a group of 29 girls and 12 boys. 8

Children diagnosed with changes in body functions and structures by known etiology with specific conditions represent 35.4% of the EIC population. 78.8% of the children have Atypical Development with Changes in Relationship and Communication, 76.9% of which were male and 1.9% female. According to the literature, this is the most common situation. Due to the numerical expression in the population served, it is understood that data confirm that the pathology which the Occupational Therapist mostly intervened at school age is the group of Autism Spectrum Disorders (ASD). 2,7,9,12

The remaining children assisted due to specific conditions of known etiology have chromosomal, metabolic and neurological abnormalities and also congenital malformations, which totals 21.2% of the cases of cerebral palsy, chromosome 8 and 13 alterations and hands and feet malformations (supernumerary fingers and toes).

Learning difficulties/sensory integration in preschool phase (4 to 6 years old) represent 8.5% of the situations. This is a group where concerns about entering primary school were found.

Concerning the situations related to severe risk of developmental delay due to exposure to biological risk factors, 6.9% refer to 12 children born prematurely (all after 27 weeks of pregnancy) and 1 child with fetal alcohol syndrome. In the initial evaluation, mothers attributed prematurity to their age, physical exertion, stress, low neonatal surveillance (appointment with the doctor after 12 weeks of pregnancy) 2,7,9,12

Regarding the origin of the signs received, 35.6% of the situations were suggested in the meeting of the Local Intervention Team, 18.7% by recommendation of the family doctor, 14.6% came from the District Hospital. 15.1% from the Community Care Unit, 13.2% indicated by the Family and 2.7% came from Children and Youth Protection Commission (CYPC). In short, these are numbers that instigate curiosity and, at the same time, bring satisfaction because family, which have a major influence on child's life, (biological or adoptive) sought the OT service because they were familiar with the work in previous situations, because known people know it, through someone who has spoken to them about service in the community or even by "word of mouth". All of those are factors that should be considered in the community due to the proximity to families and children at a key age before 6. Also important are parents who promote engagement, independence and social interaction. 3

Regarding SH, over his or her school life, the student with Special Educational Needs (SEN) shows learning problems that need more educational resources and specific attention. The difficulties of these students may be permanent or temporary. The work developed by OT in school context includes various interventions, addressed to different ages and pathologies. Also at this age, family-centered intervention based on natural life routines and contexts promotes the inclusion of children with special needs, which is a child/young person with the same rights and the same conditions to promote his or her development.

CCCU TO data between 2005 and 2016 are part of the literature, since the 64 referenced and monitored situations during the school period are between 6 and 12 years old inclusive. No situation arose after the age of 13 to 18 years.2, 4, 7 It is a group with more boys than girls.

The situations were distributed in 4 large groups: alterations of body structures and functions due to developmental delay due to specific conditions that mostly left the EIC (45.3%); serious risk of developmental delay due to exposure to biological risk factors (1.6%); learning/sensory integration difficulties in preschool phase (7 to 10 years) (46.9%) and finger fractures of one hand (6.2%) due to falls.

It has been recognized a major issue concerning the difficulties of learning and sensory integration, with a percentage of 46.9. Whether because the child does not learn or does not follow the normal rhythm, or due to other "complaints" essentially shown in mediocre tracing, not being able to hold the pen properly, to sit or to keep up with the class, the act of beating their colleagues and having an inappropriate behavior.

There were registered 35% of situations by the Community Care Unit, 25% by the Grouping of Schools, 20% by the family doctor, 16.7% by the family and 3.3% by the Children and Youth Commission.

The type of assistance (more individual than in group), even though there was more group care than in EIC (once a week), parents with less presence than in EIC (despite being involved in the objectives/strategies, especially those that should be performed at home daily), in an intervention mostly made in the context of a Health Unit. It is easy to understand the reason: the particularity of situations and intervention centered on the Family and the Child, based on individualized care performed at earlier ages. 2, 4

In situations where this transition occurred, informal meetings with the OTs of the School Groupings were held to discuss the support already made, bearing in mind the continuity and a "smooth" transition between professionals in the same professional area. Many situations were "discharged" at the age of 7 because they had been receiving support for 2 to 4 years at NSEI. Frequently, this "discharge" is not due to the needs of the young person, but to the needs of the CCCU TO service. This service needs to assign vacancies to children at an early age that, in the meantime, came up and needed an appointment and support due to health conditions, changes in structures and functions of the body, to an established/known condition, or because they are directly eligible in NSEI, a project considered a priority.

Conclusions

In total, between March 2005 and March 2016 (with an interruption in 2013) 253 children/young people, from 0 to 12 years old were assisted (once or more times) by CCCU TO: 88.6% individually and only 11.4% in group.

To assist 253 children/young people over 10 years corresponds to an average of 25 children per year, which is a real "adventure" if one thinks that many of them (due to their proven difficulties) do not need some kind of care that will end in 6 months or 1 year.

Many start an early care service (usually when they are between 2 and 3 years old) and are assisted at least up to the age of 6 (inclusive), until entering school, many of them with school delay due to the difficulties.

Family-centered intervention does not only depend on the intervention context or the domain of activity. It also depends on the type of assistance and the philosophy underlying the intervention, which can focus on the family in all the main natural life contexts. We do that whenever possible and useful. Regarding the support provided at the health unit, parents are always present. This represents a collaborative partnership. 3, 7,12

Most of the children were treated under NSEI. In the area of SH, the vacancies were prioritized by those who did not have support in their school context and that have never had support from OT. Thus, it has been ensured that all children and young people who need assistance have access to the service at least once in their early childhood/adolescence. It is not a 1 hour per week per child/family that makes a difference, but wanting to get at least 1 hour a week per each child/family can make all the difference in their lives because it is not a "replacement" it is rather a way of saying "I indicate these solutions" or "tell me what tools do you have in place to go hand in hand". Many children also need to have their families by their side, and that they are capable and can cooperate with the "negotiation" contract in the Individual Plans of Intervention, usually combined. 13

Regarding the way of intervention, it was observed that in the EIC, 63.1% of the interventions were performed in Community Structures, 29.1% in the Health Unit and 7.8% at Domicile. It was questioned the procedure of the service done by OT, concerning the fact of being truly centered in the family, culminating in the question, "Is the approach used truly centered in the family?". And the answer is "Yes, absolutely." Even if associated with the service (lack of time, transportation, maximization of resources), it is done in the health unit. 3

It is clearly a child who has difficulties at an early age (her situation is resolved at a given time), but that may (or may not) need a new help and a new strength in his or her life. We have this concern, although it is limited in space and time by the CCCU time ratio (18 hours out of 35), which is clearly insufficient.

Another point is that the work of an OT in childhood and youth goes beyond the care of the child/family, which is a strong concern of ours (currently and in the future). Care without assistance data of December 2016 (not included in the total data) indicate that they used 24 hours in care without assistance. Another worry is the substitution in maternity/minor children (time off work) and the needs in other projects that "steal" this level of intervention. 13 It is recommended to:

• Promote the articulation between levels of care, early referral

• Follow the life cycle of the child/youth with SEN and HSN (Health Special Needs)

• Reflect on non-attendance needs (meetings, reports, coding of scales, national registration platform of Local Early Intervention Teams, case management) and set priorities

• Praise families considering the warnings given and the informal partnerships established and promote the quality of life of families with a child/young person that raises concerns (even if unjustified)

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