Abstract

This paper aimed to characterize actions directed to children’s mental health (CMH) in Primary Health Care (PHC), based on an integrative review of Brazilian literature (2006-2017). The searches were carried out from LILACS, SciELO and VHL Network databases. After applying the inclusion and exclusion criteria, 13 articles were identified for analysis, which were presented in three thematic axes: 1) Characterization of the demands on CMH for PHC; 2) Actions and interventions on CMH carried out in PHC; and 3) Difficulties and propositions for the implementation of actions on CMH in PHC. The literature points, as the main actions, the identification of CMH problems and their referral to care by specialties. Some studies described specific actions of professionals such as physicians, pediatricians, and psychologists. Interventions of a local character or in partnerships with universities were also identified. The analysis of this material indicated that PHC has been considered as an important field of action in CMH, but that nevertheless requires greater investments, especially in professional training and work organization.

Key words:
Mental health; Child; Primary Health Care; Review

Introduction

Childhood mental health problems can impair child development and are often associated with psychosocial disorders in adulthood. Thus, interventions in this context become extremely important and should be understood as a preventive factor and a strategy for long-term health promotion¹1 Arpini DM, Santos BR. Programa da Criança: espaço de promoção de saúde e fortalecimento dos vínculos. Rev Psicol Arg 2007; 25(49):155-164.

2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.

3 Goodman A, Joyce R, Smith JP. The long shadow cast by childhood physical and mental problems on adult life. Proc Natl Acad Sci USA 2011; 108(15):6032-6037.

4 Ramires VRR, Benetti SPC, Silva FJL, Flores GG. Saúde mental de crianças no Brasil: Uma revisão de literatura. Inter Psicol 2009; 13(2):311-322.^-55 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.. In Brazil, a long trajectory of discussions and debates, guided by the principles of the Psychiatric Reform, was necessary for the implementation of current policies and guidelines⁶6 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72. in the scope of mental health care.

Aligned to this, the publication of the 2006 National Primary Care Policy (PNAB) was a milestone that aimed the revitalization of the Primary Health Care (PHC) in Brazil and reaffirmed it as the main mode of action and health care⁷7 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Séria Pactos pela Saúde. Brasília: MS; 2006.^,88 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012.. Currently, PHC constitutes the ordering basis of care and is characterized by a set of actions of individual and collective scopes, aiming health promotion and protection, disease prevention, diagnosis, treatment, rehabilitation and harm reduction, which aims to comprehensive care in consonance with the population’s context⁹9 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema único de Saúde (SUS). Diário Oficial da União 2017; 21 set.

10 Brasil. Ministério da Saúde (MS). Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família - NASF. Diário Oficial da União 2008; 25 jan.^-1111 Kantorski LP, Coimbra VCC, Oliveira NA, Nunes CK, Pavani FM, Sperb LCSO. Atenção psicossocial infantojuvenil: interfaces com a rede de saúde pelo sistema de referência e contrarreferência. Texto Contexto Enferm 2017; 26(3):1-10.. Within this proposal, the proximity of the health team with the community’s living spaces is highlighted as a positive factor in the approach to the child and youth population⁸8 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Básica. Brasília: MS; 2012..

In order to expand the Brazilian PHC actions, in 2008, the Support Centers for Family Health (NASF) were created. It is a service composed of a multidisciplinary team from different health fields, to work in partnership with the Family Health Strategy (ESF) services. Specifically, for children and adolescents, the potentialized actions by NASF must include the realization of therapeutic groups, family interventions and support for therapeutic projects built for individuals and their families⁹9 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema único de Saúde (SUS). Diário Oficial da União 2017; 21 set.^,1212 Jimenez L. Psicologia na Atenção Básica à Saúde: demanda, território e integralidade. Psicol Soc 2011; 23:129-139..

Particularly regarding mental health care, the National Mental Health Policy, implemented in Brazil between 1990 and 2006, encouraged the creation of services from the Psychiatric Reform perspective, as mentioned before, introducing a model of psychosocial care based on a social perspective about people under psychological distress. Thus, a service network was implemented based on the integrality of actions and intersectoral collaboration principles¹³13 Borges CF, Baptista TWDF. O modelo assistencial em saúde mental no Brasil: a trajetória da construção política de 1990 a 2004. Cad Saude Publica 2008; 24(2):456-468..

In this process, the Psychosocial Care Network (RAPS) was also instituted in 2011, with the purpose of creating, expanding and articulating places of care for people with psychological distress or psychosocial disorders¹⁴14 Brasil. Ministério da Saúde (MS). Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2011.. The promotion of care for vulnerable groups, including children, adolescents, and young people⁹9 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema único de Saúde (SUS). Diário Oficial da União 2017; 21 set., is one of the secondary objectives of this Network. The RAPS are organized from different components, such as: Psychosocial Rehabilitation Strategy, Deinstitutionalization Strategies, Hospital Care, Transitional Residential Care, Urgency and Emergency Care, Strategic Psychosocial Care, and PHC in Health⁹9 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema único de Saúde (SUS). Diário Oficial da União 2017; 21 set..

In this sense, PHC started to occupy an important place in the articulation of the mental health care network in the process of overcoming the previous biomedical model, with an asylum and medicalizing perspective. Thus, PHC, mainly in the form of the ESF and Primary Health Care (PHC) Centers, has an important role in detecting and addressing every health demands, including mental health demands, as it is the main gateway to the health care system. So, studies on Children’s Mental Health (CMH) in this context are relevant, since, as mentioned, difficulties in this area interfere on the development of the child’s potential in different areas of their lives, and interventions in these cases have preventive potential¹1 Arpini DM, Santos BR. Programa da Criança: espaço de promoção de saúde e fortalecimento dos vínculos. Rev Psicol Arg 2007; 25(49):155-164.^,22 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.^,1515 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.. Therefore, it is important to know the state of the art of Brazilian scientific publications on the subject, in order to contribute for a reflection on the current panorama of CMH care. This becomes more relevant when considering that a recent prevalence study estimated that 13.1% of children and adolescents may suffer from some psychiatric disorders in Brazil¹⁶16 Paula CS, Coutinho ES, Mari JJ, Rohde LA, Miguel EC, Bordin IA. Prevalence of psychiatric disorders among children and adolescents from four Brazilian regions. Rev Bras Psiquiatr 2015; 37(2):178-179.. Thus, this paper aimed to characterize actions on CMH in the context of PHC, based on a review of Brazilian articles published between 2006, the year of PNAB’s publication, and December 2017.

Method

This study consists of an integrative literature review, a method that offers a knowledge synthesis of multiple studies about a specific subject¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764.

18 Botelho LLR, Cunha CCA, Macedo M. O método de revisão integrativa nos estudos organizacionais. Gest Soc 201; 5(11):123-136.^-1919 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106.. In fact, among the review methods, the integrative one is the widest, as it allows the inclusion of experimental and non-experimental studies, and offers a more complete and better understanding of the studied phenomenon¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764.^,1919 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106.. In addition, for the health field, this review type brings important contributions to the Evidence-Based Practice, since the proposal for systematization and ordering contributes to a deeper understanding of the investigated topic, which can have repercussions on health practice¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764..

This integrative review was prepared following guidelines¹⁷17 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764.^,1919 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106. that encompass six phases: 1) Elaborating the guiding questions, moment when the researcher elaborates a hypothesis or research questions, in a clear, specific, and relevant way to the health field; 2) Searching or sampling the literature, when, considering the research question, criteria and the articles selection process for analysis are established; 3) Defining of information/data collection, phase in which the information to be extracted is defined, synthesizing from an instrument (in the case of the present study, a protocol prepared by the authors, containing key information to be collected in the analyzed articles); 4) Evaluation/critical analysis of the studies, when carrying out the critical analysis of the studies, considering their rigor and characteristics, in addition to the classification of evidence (in the present study, such classification was based on the evidence hierarchy described in Souza et al.¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106.); 5) Discussion/interpretation of results, a stage in which the synthesis and discussion of the main results are carried out, contemplating a comparison with theoretical knowledge; and 6) Presentation of the review, which culminates in the preparation of the document that describes all the steps, in the best possible detail, and highlights the main findings.

In this review, the search and selections of articles were made in January 2018, based on the consultation of LILACS (Latin American and Caribbean Literature in Health Sciences), SciELO (Scientific Electronic Library Online) and the VHL Network (Virtual Health Library) databases, based on combinations of descriptors registered in the Health Sciences Descriptors (DeCS). These sources were chosen because they host most of the Brazilian available articles, since it was sought the literature which portrayed the reality of CMH assistance system in Brazil. The VHL Network, which comprises several other databases, filters were also used: publication date (2006-2017), access availability, language (Portuguese) and type of publication (article).

Subsequently, in order to expand the number of results to better characterize the literature in the area, new searchers were carried out on the VHL Network using descriptors not registered in DeCS. For the adoption of this strategy, it was also considered the fact that informal searches, carried out before the selection of articles, had indicated the existence of other publications relevant to the subject, which had not been found by the exclusive use of indexed descriptors. Chart 1 shows the descriptors used in different searches.

The results found in the first search were selected based on the following inclusion criteria: type of material, considering only articles; year of publication (2006-2017); and location of the research (Brazil). Duplicate results and those that did not fit the inclusion criteria were excluded from the analysis. Afterwards, an analysis of the subjects was carried out based on the reading of titles and abstracts. In this stage, the focus of the study on CMH actions within the scope of PHC was applied as an inclusion criterion, disregarding those which only performed their data collection in this context. With the application of this theme criterion, 14 articles were selected for full reading. From this reading, six of these articles were excluded, considering as exclusion criteria not to contemplate mental health exclusively in childhood and not contemplate specifically the context of PHC. This entire selection process is shown in Figure 1.

The selection of results found from the use of descriptors not indexed in DeCS followed the same steps described above, as shown in Figure 2. This new search identified 12 articles for analysis. However, after excluding duplicate results, considering the articles selected from the first search, made with indexed descriptors, only 5 articles remained for analysis. Adding these five articles to the eight selected in the first search, there was a total of 13 articles for the analysis.

Considering the articles selected for analysis in the first search (carried out with indexed descriptors) through the VHL Network, it was verified that they were indexed, considering their repetitions, on the following databases: LILACS, Medline, CidSaúde, Index Psi and BDENF. As for the articles selected in the second search, carried out with descriptors not indexed in DeCS, it was observed that they were indexed on Index Psi, LILACS and BDENF databases.

All searches, selections, and exclusions from the results were carried out by two judges, authors of the article, simultaneously and independently. In situations of disagreement, a third judge (also author) was consulted for decision making.

For the analysis of the 13 articles included in this review, a protocol was created with descriptive indicators based on three thematic axes: 1) Characterization of the demands on CMH for PHC; 2) Actions and interventions on CMH carried out in PHC; and 3) Difficulties and propositions for the implementations of actions on CMH in PHC. These axes emerged from the full reading of the 13 articles.

Results

Chart 2 details the year of publication, objectives, and methodological focus of the analyzed articles. From 2012 onwards, an increase in publications on the thematic can be noticed, since 70% (n=9) of the analyzed articles were published between 2012 and 2017. It was highlighted, as most frequent objectives, the description and assessment of care strategies on PHC, the health professional perceptions about CMH actions, as well as the characterization of the population. As methodological approach, 10 articles (77%) were empirical, two (15,5%) were experience and case reports, and only one (7.5%) presented a theoretical basis. Most empirical studies focused on qualitative methods (n=5, 50%), followed by quantitative (n=3, 30%) and mixed (n=2, 20%).

Chart 3 presents in detail the methodological characteristics of the analyzed articles. Among the empirical studies (n=10), the following were identified as participants: children (n=6, 60%), parents or family (n=6, 60%) and health professionals (n=6, 60%). It is important to consider that 6 (60%) articles accessed more than one of these groups (for example, parents and professionals, or parents and children). Among the studies that included assisted children by health services, it was identified that in three (50%) the data came from medical records and, in five (83%), also from referred information or instruments filled out by family members. Among the children’s age, five studies (83%) targeted the period from 5 to 12 years of age. Only two empirical studies and an experience report covered children of a lower age group. In addition, an empirical study involved children from one to nine years old, divided into two age groups.

There was a diversity of strategies for data collection, including interviews (n=6, 60%), standardized instruments for the symptom’s identification (n=4, 40%) and the characterization of the family context (n=2, 20%), questionnaires (n=3, 30%), data from medical records (n=3, 30%), field diary (n=1, 10%) and photographs (n=1, 10%). As for data analysis, it was used, as qualitative methods, thematic analysis (n=5, 50%), socio-historical (n=1, 10%), phenomenological hermeneutics (n=1, 10%) and ecomap (n=1, 10%). Among quantitative methods, statistical analyses were identified as descriptive (n=5, 50%), comparatives (n=3, 30%), correlational (n=1, 10%), and the use of univariate and multivariate regression (n=1, 10%).

Chart 3 presents the critical evaluation of the studies that sought to identify the appropriate description of the participants and the adequacy of the methods in relation to the proposed objectives in each study, in addition to the validity of the evidence¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106., especially related to the results discussed in this paper. The parameters used to analyze the evidence levels were described in Souza et al.¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106., considering: Level 1 (evidence resulting from meta-analysis), Level 2 (evidence resulting from experimental design studies), Level 3 (evidence resulting from quasi-experimental studies), Level 4 (evidence from descriptive studies or qualitative approach), Level 5 (evidence from case or experience reports), and Level 6 (evidence from expert opinion). Among the 13 articles analyzed, there was a predominance of Level 4 evidence, due to the greater number of qualitative studies identified, and adequacy in the methodological descriptions.

The main results of the analyzed studies are presented below, based on the integration of the information contained in each of the thematic axes of the descriptive protocol designed to record the information of this paper.

Characterization of the demands on CMH for PHC

Eight of the 13 analyzed articles referred to this thematic axis. Some articles characterized these demands based on the prevalence data. In the study by Ferriolli et al.²2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259., of the 100 children (6 to 12 years old) evaluated from the city of Ribeirão Preto (Southeastern Brazil), 31 were classified as at risk for emotional/behavioral disorders. Anxiety and depression symptoms were the most frequent (39%) and mental health issues were predominantly associated with financial instability and maternal distress. Santos and Celeri¹⁵15 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90., on the other hand, from a sample of 40 children (30 to 50 months old) from a city in the interior of São Paulo, identified in more than half of them, a risk for the development of mental health issues.

A survey of 104 medical records carried out by psychologists in seven PHC Centers in the city of São Paulo (Southeastern Brazil), conducted by Braga e Morais²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51., pointed out that 76.9% of them had school complaints. It was also found that 51.9% of these complaints were due to referrals made by schools. Other studies have also identified demands on CMH in PHC due to referrals made by schools or related to school complaints⁶6 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.

21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.

22 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^-2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.. In relation to this, there is a lack of consensus in the literature on the real demand for the referrals⁶6 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258..

Furthermore, some studies have characterized CMH demands for PHC from the perspective of physicians and pediatricians²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.. For these, the demand is often already formulated by the family, and usually involves suspicions of physical diseases and is related to the expectation of drug interventions or referrals²³23 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.. Demands are also perceived to be associated with other contexts, such as schools, family situation or socioeconomic problems²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486..

Actions and interventions on CMH carried out in PHC

Several studies (n=12 articles) focused on describing actions and interventions on CMH were carried out within the scope of PHC. The most frequent actions referred to the identification/diagnosis of CMH issues¹⁵15 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.

25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^-2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370. and referral to specialty services²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.

24 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.^-2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.. Some studies referred to the work of some professionals in specific, while others described interventions carried out by health professionals or staff in partnership with other institutions or through local programs.

Studies that addressed the physician and pediatrician work indicated as main activities those related to the identification and referral, in addition to medication prescription²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.. Tanaka and Lauridsen-Ribeiro²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486. described that the conduct most frequently adopted by pediatricians in face of CMH issues in one PHC Center in São Paulo, was orientation (23.6%) and referral to a mental health service and Speech therapy (15.3%). The authors also highlighted that 29.2% (n=21) of children with a hypothetical diagnostic of mental health disorders had no medical conduct described in their medical records.

Gomes et al.²³23 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258., in an investigation in PHC Centers and ESF in Divinópolis (Southeastern Brazil) presented the physician and pediatricians’ perception about their interventions. The orientation activity was mentioned by these professionals. Regarding medication administration, they indicated that there was no dialogue with the specialist, either the child was already on medication, or simply had their prescription renewed during the appointment. The interviewees did not agree with the way the referrals were instituted, frequent outcome being drug intervention. However, they did not propose any other intervention. Likewise, they reported preventive activities or developmental monitoring were not performed, as they consider them a responsibility of Nursing professionals.

On the other hand, Becker et al.²²22 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251. described an intervention carried out by medical students, based on an internship experience. The case study described an intervention carried out in PHC Center for the reception of a child (5 years old) referred by the school, who expressed a desire to die and assault schoolmates. Due to the ineffectiveness of the proposed intervention and the side effects of the medication, the case was directed to the team of interns. The team reorganized the care plan based on the Safety Circle concept, which establishes emotional support and instructions for parents and health professionals about providing of a safe environment for the child to develop their emotions. In this way, interventions that addressed the family, the PHC Center and the school attended by the child were articulated, a positive strategy and alternative to pathologization and medicalization.

Particularly about the psychologist’s work, Braga and Morais²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51. described the most frequently adopted conduct by this professional in PHC Center in the city of São Paulo (Southeastern Brazil), in relation to a sample of 104 children’s medical records: family orientation (24.7%), followed by group therapy (20.5%) and individual therapy (15.3%). However, they noticed differences among the cases that did not involve school complaints, as in these the most used intervention was individual therapy. In only 1% of the cases that looked for the PHC Center services with school complaints, an interview with the teacher was conducted. For the authors, this demonstrates that health professionals understand these complaints as susceptible to clinical treatment, disregarding the complex network which involves other relationships imbricated in school difficulties.

However, an interdisciplinary work (Psychology and Nursing) was described by Arpini et al.²⁷27 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50.. It consists of an activity carried out by Federal University of Santa Maria (UFSM) together with the Children’s Program in the city of Santa Maria (Southern Brazil). The actions included clinical assistance, which encompassed the Nursing work, through monitoring and general orientation on child’s care, and Psychology, focused on relational aspect (parents-child relationship). The technical resources used in the Psychology’s work were observation guided by IRDI (Clinical Risk Indicators in Child Development); interviews with family members; guidance to family members and referral, when necessary, to other health professionals or health services. According to the authors, this project represents an early detection strategy for development risks, and for health prevention and promotion.

Tszenioski et al.²⁶26 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370. described interventions carried out by Occupational Therapy students, based on an action research project, articulated with one PHC Center in Recife (Northern Brazil). The interventions were presented as possibilities for the performance of these professionals on CMH, whose work is characterized by the discovery of abilities that stimulate the children’s potentialities, in order to promote greater independency and autonomy. Stimulation activities were carried out through interventions based on the importance of playing, including the training of psychosocial and cognitive abilities. The research team also assessed the health network and set goals together with the families and health teams from different services. In the authors’ evaluation, the proposed interventions contributed for the strengthening of the care network, providing greater articulation between the PHC team and the specialized service, in addition to strengthening bonds among some children and their families and schools.

The presented actions so far refer to interventions developed by some health professionals in PHC Center and ESF or in projects in partnership with universities. However, Carvalho et al.⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85. described, based on different specialties, activities from a specific governmental program, of a local nature, called Municipal Program for Early Intervention (PMIB). It is an initiative promoted by the city of Campina Grande (Northern Brazil), which seeks to support children between 0 and 6 years old who are at risk of developing disorders throughout their development, and assist their families, aiming to identify problems or prevent impairments, in addition to promote the integration and inclusion of these children in family and society. According to the authors, inside the PHC context, even though the health professionals from different specialties recognize in their labor an opportune moment for early intervention and detection of risk signs, several of them do not feel qualified for such interventions.

Other articles²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351. also made specific mention to the psychological violence cases received in PHC, due to their repercussion on CMH, and the necessary intervention to interrupt the cycle of maltreatment. Specifically, Silveira et al.²⁸28 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351. pointed out that the different professionals from PHC in a city in Southern Brazil prioritized the physical signs of violence while underestimating the psychological ones. The authors also identified the absence of a specific action to detect psychological violence against children and the professionals’ difficulties to intervene in effectively.

As seen so far, several studies identified referral as an important part of CMH actions to be performed by PHC professionals. However, Cavalcante et al.²⁵25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178. emphasize that, when receiving and making a clinical evaluation for later referral, the PHC professional must know how to recognize which demand the service can assist and who, in fact, should be referred for specialized care. Finally, even though it is not an CMH action related to the supported population, Cavalcante et al.²⁵25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178. mentioned the matrix support as an important tool to the rear activities of the PHC’s professional. It is a strategy that, several times, makes the CMH interventions possible to be carried out in the PHC context.

It should also be underlined that several actions described in the reviewed studies were developed from and articulation with different sectors. Among them, we highlight the interlocution with the families⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.

21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.

22 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^-2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2727 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50., health care network and childhood²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.

26 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.

27 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50.^-2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351., and school institutions²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2222 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370..

Difficulties and propositions for the implementation of actions on CMH in PHC

Finally, several articles (n=12) also discussed the difficulties faced for the effective implementation of the presented actions, as well as presented proposals to remedy them. Some difficulties mentioned were related to the health professionals, such as lack of preparation or security to deal with the child population who needs mental health care²2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.^,55 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,1515 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.

24 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.^-2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351.. This limitation was sometimes mentioned based on a personal difficulty, related to the professional’s emotional aspects, or from a difficulty in acknowledging of the demands which can be met in PHC or which should be referred to the specialties²⁴24 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.

25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^-2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.. They also mention greater attention to organic complaints to the detriment of psychological aspects²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351., which are sometimes minimized, either in relation to clinical conditions¹⁵15 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90. or in relation to psychological violence cases²⁸28 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351..

Specifically, about the pediatrician, difficulties were mentioned in acknowledging CMH issues, so that these professionals perceive that they do not have the same property to deal with mental health issues in comparison to other specialties²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.. Some justifications to the incapacity of accommodating the demands on CMH were related to the mental health language, to traits of the professionals themselves and the flaws in training²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.. In this direction, some studies²2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.^,1515 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351. addressed the importance of early detection of CMH issues and have proposed an implementation of protocols sensitive to childhood to qualify this process.

Regarding psychology professionals, it was pointed out that they often have difficulties in seeking other ways to intervene beyond the individual psychotherapy, due to the predominant clinical perspective in their graduation²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.. In this sense, it is recognized that the training and qualification of the professionals is still against the Psychiatric Reform guidelines and mental health, privileging interventions, and the traditional psychopathology and fragilizing, on the other hand, comprehensive care²⁵25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351.. In fact, the fragmented understanding of health and the processes underlying pathologization have been described in some articles as a barrier to care on CMH in PHC⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,66 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2222 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178..

As seen, several studies pointed out the need for further investments in professionals’ training, for the consolidation of CMH practices in PHC²2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.^,55 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,66 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853.

25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^-2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351.. In this sense, some authors²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351. highlighted the need for investments both in continuous education and in the revision of undergraduate curricula. Among the suggestions, proposals of training including intervention practices²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486., and those which can break the logic of specialties and privilege of biological aspects in relation to the mental health ones⁶6 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351. were identified.

In addition to individual and training aspects, other difficulties for the implementation of CMH actions in PHC are related to the organization and articulation of the services⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351.. In this direction, difficulties related to referral were listed, such as excessive demand, lack of knowledge of professionals in relation to the functioning of the networks, as well as difficulties in articulation between services²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351.. Thus, several articles pointed out the need for further investments in work organization, both at the health unit and in the articulation with other instances of the intra and intersectional care system, in an interdisciplinary way, contemplating the matrix support and the implied referral⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,1515 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853..

Discussion and final considerations

This review aimed to characterize actions on CMH in the context of PHC, through an integrative review of Brazilian literature (2006 to 2017). From the analysis of 13 articles, an increase in the publication on this thematic in recent years was identified, probably due to the time of PNAB’s implementation, which occurred in 2006. The revised articles also indicated the acknowledgement of PHC as an important field of CMH action. The main actions described in this context were characterized by the identification of CMH issues and referral to specialties.

Some studies described specific actions by some professional categories, such as physicians, pediatricians, and psychologists. However, caring for less severe childhood mental health issues, which could be followed up within the PHC scope²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178., were hardly mentioned. This process may reflect the difficulties of the PHC teams in receiving the necessary support for the children and adolescents’ care, since the literature has indicated obstacles in the articulation with specialized teams through matrix support²⁵25 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.^,2929 Machado DKSM, Camatta MW. Apoio matricial como ferramenta de articulação entre a saúde mental e a atenção primária à saúde. Cad Saude Colet 2013; 21(2):224-232.^,3030 Gama CAP, Campos RO. Saúde Mental na Atenção Básica - Uma pesquisa bibliográfica exploratória em periódicos de saúde coletiva (1997-2007). Cad Bras Saude Mental 2009; 1(2):1984-2147.. On the other hand, it can also be related to training aspects of these professionals, still guided by the logic of specialties, so that they do not perceive issues related to mental health as part of their work at PHC⁶6 Sinibaldi B. Saúde mental infantil e atenção primária: relações possíveis. Rev Psicol UNESP 2013; 12(2):61-72.. In this sense, it is worth questioning whether, in fact, these consultations do not occur, and are referred directly to the specialties, or whether they are not recognized by professionals as mental health interventions.

This review also identified private interventions, of a local nature or in partnerships with universities, through internships, university extension programs and intervention research. In these, a more comprehensive understanding of childhood was identified, contemplating actions of an interdisciplinary or intersectoral characters and attention to the relationships between the agents and institutions involved in the intervention. These experiences demonstrate that the interlocution between higher education institutions and PHC has a lot to contribute to the implementation of effective CMH actions. Understanding this exchange allows us to identify, in addition to an academic training process attentive to the specificities of public health, the possibility for services to rethink and expand their mental health actions and interventions. Alongside this, local interventions have also pointed out possible ways for thoughtful care to specific demands and the organization of work in each location⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,2222 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2727 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50..

Some revised studies have described interventions that involve different sectors in articulation with the actions developed by PHC. It is highlighted, in this sense, the articulations with the families⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,2020 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.

21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.

22 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^-2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2727 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50., pointed out as important either for the illness as for mental health promotion; with the other services of the health and childhood assistance network²¹21 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2525 Cavalcante CM, Jorge MSB, Santos DCM. Onde está a criança? desafios e obstáculos ao apoio matricial de crianças com problemas de saúde mental. Physis 2012; 22(1):161-178.

26 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.

27 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50.^-2828 Silveira TBD, Oliveira AMND, Algeri S, Susin LRO, Baisch ALM, Marques L A, Silva PAD. A invisibilidade da violência psicológica pelos profissionais de saúde. Rev Bras Crescimento Desenvolv Hum 2016; 26(3):345-351., both in relation to the services to which referrals are made, and their necessary interlocution in the composition of therapeutic project, as well as those that offer the necessary support so that PHC itself can attend less complex cases; and also articulations with school institutions²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2222 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370., as they are responsible for most of the referrals and are acknowledged as capable of producing or minimizing child psychological distress.

Thus, the importance of intersectoral interventions as a strategy for the composition of an effective care network is reiterated. In addition, we highlight the importance of CMH actions and interventions in PHC be based on territoriality, in order to organize the care strategies among health services and other health care and support networks, such as the family and school, taking into account the context and the reality of the territory; and for the integrality of care, in the articulation of different knowledge and services of the network, contemplating, beyond mental health, the bond and social insertion as important factors for health promotion⁵5 Carvalho RN, Gondim ACS, Azevedo EB, Cavalcanti PB, Ferreira Filha MO, Queiroz D. Concepções dos profissionais da Estratégia Saúde da Família sobre intervenção precoce em saúde mental. Rev Gaucha Enferm 2013; 34(1):79-85.^,2222 Becker ALMM, Souza PH, Oliveira MM, Paraguay NLBB. A articulação da rede de proteção à criança e a aplicação intersetorial do círculo de segurança como alternativas à medicalização. Rev Paul Pediatr 2014; 32(3):247-251.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.^,2727 Arpini DM, Zanatta E, Marchesan RQ, Savegnago SDO, Bernardi PH. Intervenções precoces na infância: observando a relação mãe-bebê em um serviço de saúde. Psicol Rev 2015; 21(1):37-50.. It is also worth highlighting the amplitude of the effects of interventions in PHC, which, in addition to health promotion and prevention, can reduce the burden on specialty services, qualifying care at all levels.

The results of this review also allow us to realize that some difficulties identified in the articles regarding CMH actions in PHC in Brazil remained throughout the analyzed period. The difficulties in implementing the actions show inconsistencies between the guidelines and how, in fact, the network’s interventions are organized. The identification of these contradictions converges with the literature³¹31 Paula CS, Zaqueu L, Thais V, Lowenthal R., Miranda C. Atuação de psicólogos e estruturação de serviços públicos na assistência à saúde mental de crianças e adolescentes. Psicol Teor Prat 2011; 13(3):81-95.^,3232 Teixeira MB, Couto MCV, Delgado PGG. Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras. Cien Saude Colet 2017; 22(6):1933-1942., which shows that PHC professionals sometimes guide their actions based on a traditional and hierarchical model of assistance. Particularly in this review, the need for investment in expanding the professionals’ training was highlighted, contributing both to their technical qualification and in relation to how they understand CMH care.

Other bibliographic review studies which articulated mental health and PHC also pointed out some characteristics of this articulation identified in this paper, such as the difficulties of professionals, obstacles in the functioning of services and flaws in the training in the area³³33 Martins AKL, Braga VAB, Souza AMA. Práticas em saúde mental na estratégia saúde da família: Um estudo bibliográfico. Rev Rene 2009; 10(4):165-172.

34 Souza LGS, Menandro MCS, Couto LLM, Schimith PB, Lima RP. Saúde Mental na Estratégia Saúde da Família: revisão da literatura brasileira. Saude Soc 2012; 21(4):1022-1034.^-3535 Paula CS, Lauridsen-Ribeiro E, Wissow L, Bordin IAS, Evans-Lacko S. How to improve the mental health care of children and adolescents in Brazil: Actions needed in the public sector. Rev Bras Psiquiatr 2012; 34(3):1022-1034.. In this sense, it is possible to perceive that the implementation of mental health intervention strategies is still a challenge for PHC and for the entire care network. Specifically, about childhood, the complexity can become even greater, due to the population’s specificities. These barriers indicate complex issues, which go beyond the PHC context, however, concern the services structuration and their articulation as a whole. In this sense, it is clear that any effective changes to modify this panorama need to involve actions in different levels and constant reflection, based on continuous training, permanent education, the revision of the undergraduate curricula, in addition to the need to management follow-up and restructuration of services, in view of how they have been operating.

Regarding the methodological aspects, some considerations are highlighted. Several studies have characterized the children’s sample - target in mental health care, either from standardized instruments²2 Ferriolli SHT, Marturano EM, Puntel LP. Contexto familiar e problemas de saúde mental infantil no Programa Saúde da Família. Rev Saude Publica 2007; 41(2):251-259.^,1515 Santos, RGH, Celeri EHRV. Rastreamento de problemas de saúde mental em crianças pré-escolares no contexto da atenção básica à saúde. Rev Paul Pediatr 2017; 36(1):82-90.^,2121 Tanaka OY, Lauridsen-Ribeiro E. Ações de saúde mental na atenção básica: caminho para ampliação da integralidade da atenção. Cien Saude Colet 2009; 14(2):477-486.^,2424 Tanaka OY, Lauridsen-Ribeiro E. Desafio para a atenção básica: incorporação da assistência em saúde. Cad Saude Publica 2006; 22(9):1845-1853. and from medical records, questionnaires, or the professionals’ perceptions themselves²⁰20 Braga SG, Morais MLS. Queixa escolar: atuação do psicólogo e interfaces com a educação. Psicol USP 2007; 18(4):35-51.^,2323 Gomes FMA, Cintra AMO, Ricas J, Vecchia MD. Saúde mental infantil na atenção primária à saúde: discursos de profissionais médicos. Saude Soc 2015; 24(1):244-258.^,2626 Tszesnioski LC, Nóbrega KBG, Lima MLLT, Fagundes VLD. Construindo a rede de cuidados em saúde mental infantojuvenil: intervenções no território. Cien Saude Colet 2015; 20(2):363-370.. Both strategies allow the identification of the CMH’s demands in PHC, which is particularly important, considering that identifying the real need for health care allows more assertive actions, either in terms of interventions, by professionals, or in terms of management, through the implementation or update of the services are concerned with the population’s characteristics. On the other hand, regarding the professionals’ perception, it becomes interesting to understand how, in fact, the health care strategies are being operationalized, as this data can serve as a subsidy for the implementation of continuous education activities that consider the current panorama of the PHC services and professionals, qualifying the service to the population.

Based on what was stated, it is expected that this review will contribute to expand knowledge about the current state of the art of Brazilian scientific publications that address actions and interventions on CMH in the context of PHC and promote reflections about the professional’s performance. This paper has some limitations, mainly related to the restriction of the analyzed material, considering that types of scientific publication other than articles were not included. In addition, the low number of Brazilian publications on the subject denotes the need for greater dissemination of CMH actions carried out within the context of PHC. Still, the identification of only studies with levels of evidence 4 and 5 suggests the need to conduct research from other designs, especially quantitative and experimental to, for example, qualify the evaluation of the interventions¹⁹19 Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein 2010; 8(1):102-106..

Likewise, it is recommended to expand characterization studies of this demand in PHC, for better planning of professionals’ actions and interventions. The difficulties encountered in the search for articles also suggest the need for standardization in the descriptors’ indexing about this theme, considering that it is a field of specific study and practice, necessary and important for the health field as a whole.

Acknowledgments

To the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for the financial support in the form of a Research Productivity Grant to the author DC Levandowski, and a PhD-GD Grant (linked to the PPG Psychology at UFRGS) to the author GC Esswein.

References

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