ASSISTANCE TO ADOLESCENTS WHO USE PSYCHOACTIVE SUBSTANCES: ROLE OF THE PSYCHOSOCIAL CARE CENTER ATENDIMENTO AO ADOLESCENTE USUÁRIO DE SUBSTÂNCIAS PSICOATIVAS: PAPEL DO CENTRO DE ATENÇÃO PSICOSSOCIAL

The present study aimed to gain insight into the role of a Psychosocial Care Center for Users of Alcohol and other Drugs (CAPS AD) that assists adolescents who usepsychoactive substances, from the views of the professionals of Guardianship Councils and the Judiciary. Qualitative researchconductedfrom June to August 2015, in units of a Psychosocial Care Network (RAPS) for adolescents, in a city of the state of Rio Grande do Sul, based on semi-structured interviews with 13 professionals from Social Work and the Judiciary. Two categories emerged from data analysis: The role of the Psychosocial Care Center Alcohol and other Drugsand Challengesfaced bythe CAPS professionals regarding the delivery of care who use alcohol and other drugs. DESCRIPTORS: Adolescents; Mental health; Substance-related disorders. ASSISTANCE TO ADOLESCENTS WHO USE PSYCHOACTIVE SUBSTANCES: ROLE OF THE PSYCHOSOCIAL CARE CENTER ATENDIMENTO AO ADOLESCENTE USUÁRIO DE SUBSTÂNCIAS PSICOATIVAS: PAPEL DO CENTRO DE ATENÇÃO PSICOSSOCIAL RESUMO: O estudo teve como objetivo conhecer o papel de um Centro de Atenção Psicossocial Álcool e Outras Drogas no atendimento ao adolescente usuário de substâncias psicoativas, na perspectiva dos profissionais que atuam no conselho tutelar e no judiciário. Pesquisa qualitativa, realizada entre junho e agosto de 2015, em serviços da Rede de Atenção Psicossocial ao adolescente, em um município do estado do Rio Grande do Sul, a partir de entrevistas semiestruturadas com 13 profissionais da Assistência Social e do Judiciário. Após análise dos dados, emergiram duas categorias: O papel do Centro de Atenção Psicossocial Álcool e outras drogas; e, Desafios no atendimento prestado aos adolescentes pelo Centro de Atenção Psicossocial Álcool e outras drogas. Concluise que há necessidade das intervenções realizadas com adolescentes usuários estarem pautadas na perspectiva interdisciplinar, intersetorial e com profissionais qualificados, a fim de potencializar as ações de atenção à saúde para atender essa demanda. DESCRITORES: Adolescente; Saúde mental; Transtornos relacionados ao uso de substâncias. Corresponding author: Received: 09/08/2016 Amanda de Lemos Mello Finalized: 09/02/2017 Universidade Federal de Santa Maria Av. Roraima, 1000 97105-900 Santa Maria, RS, Brasil E-mail: amandamello6@yahoo.com http://dx.doi.org/10.5380/ce.v22i1.48011 Original article 1Social worker. Specialist in Mental Health. Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. 2Psychologist. Specialist in Mental Health. Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. 3Nurse. Specialist in Mental Health. Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. 4Psychologist. Specialist in Mental Health. Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. 5Nurse. PhD student in Nursing. Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. 6Nurse. PhD in Nursing. Professor of Nursing at Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. Cogitare Enferm. (22)1: e48011, 2017 ATENDIMIENTO AL ADOLESCENTE USUARIO DE SUSTANCIAS PSICOACTIVAS: PAPEL DEL CENTRO DE ATENCIÓN PSICOSOCIAL RESUMEN: Estudio cuyo objetivo fue conocer el papel de un Centro de Atención Psicosocial de Álcohol y Otras Drogas en el atendimiento al adolescente usuario de sustancias psicoactivas, bajo la perspectiva de los profesionales que actuan en el consejo tutelar y en el judiciario. Investigación cualitativa, realizada entre junio y agosto de 2015, en servicios de la Red de Atención Psicosocial al adolescente, en un município del estado de Rio Grande do Sul, con base en entrevistas semiestructuradas a 13 profesionales de la Asistencia Social y del Judiciario. Resultaron dos categorias del análisis de los datos: el papel de la Atención Psicosocial de Álcohol y Otras Drogas; y, Desafíos en el atendimiento prestado a los adolescentes por la Atención Psicosocial de Álcohol y Otras Drogas. Se concluye que hay necesidad de que las intervenciones realizadas con adolescentes usuarios estén pautadas en la perspectiva interdisciplinar, intersectorial, además de la priorización por profesionales calificados, con fines de potencializar las acciones de atención a la salud para atender a esa demanda. DESCRIPTORES: Adolescente; Salud mental; trastornos referentes al uso de sustancias. Bruna Rios Paim1, Daniele Dalla Porta2, Diana Mara Sarzi3, Mirela Frantz Cardinal4, Daiana Foggiato de Siqueira5, Amanda de Lemos Mello5, Marlene Gomes Terra6


INTRODUCTION
The use of Psychoactive Substances (SPA) has increased significantly in the last decades, reinforcing the need for reform in the public policies targeted to users of alcohol and other drugs.In Brazil, the Brazilian Psychiatric Reform movement that advocated the de-institutionalization of people with mental illness and the Psychiatric Reform Law No. 10.216 of April 6, 2001 are a milestone in this process, revealing the importance of the adoption of more humanized treatments, of concern with the particularities and the rights of people with mental suffering or disorders, as well as of people with alcoholism and other drug use disorders (1) .
Regarding child and adolescent care, the public policies have always been based on the institutionalization of the referred population.However, since the establishment of the Child and Adolescent Statute (ECA) and the Psychiatric Reform, many actions have been implemented in an attempt to change this model of care.Thus, in 2004, the National Forum on Mental Health of Children and Adolescents proposed the foundations and guidelines for a public policy targeted to children and adolescents' mental health care (2) .Thus, the Brazilian Child and Adolescent Mental Health Policy that recommends the deinstitutionalization of this population and greater concern with their peculiarities and needs was created (2) .The implementation of this policyinvolved new models of care, such as the Psychosocial Care Centers (CAPS), established by Ordinance No. 336 of February 19, 2002, of the Brazilian Ministry of Health (3) .
The CAPS are part of the Mental Health Care Network, according to the Brazilian Psychiatric Reform Law, and aim to integrate users and families into a social and cultural space, as well as to their cities.The new model of care attempts to create a network of care for the referred population in this territory by providing an environment that maximizes the impact of health actions (4) .
Among the different types of CAPS, those destined to the care of psychoactive substance users are known as CAPS Alcohol and Drug Users (CAPS AD).These centers have been playing a key role in the organization of the community network since the creation of the Psychosocial Care Network (RAPS) by the Ministry of Health (Ordinance No. 3088 of December 23, 2011).The RAPS aims at creating, expanding and coordinating health care units for people with mental suffering or disorders associated to the use of psychoactive substances.Thus, RAPS services must be aware of increased use of drugs by adolescents and offer high quality treatment to this age group (5) .
In this regard, the delivery of appropriate treatment for adolescents who use psychoactive substances deserves urgent consideration due to the lack of suitable places and health professionals to meet their unique demands (6) .The present study may stimulate health professionals to reflect about their health practices targeted to adolescents, contributing to the improvement of these practices and meeting the needs of this population and the RAPS.
In view of the aforementioned, the present study aimed to gain knowledge aboutthe role of a CAPS Alcohol and Other Drugs (CAPS AD) targeted to adolescents who use psychoactive substances, from the views of the professionals of Guardianship Councils and the Judiciary.Qualitative descriptive exploratory study (7) involving 13 intentionally invited professionals: 10 guardianship councilors, one public defender and two prosecutors of the Juvenile Court, who have been providing services at the RAPS, specifically in Social Assistance (Guardianship Councils) and in the Judiciary (Public Prosecutor's Office and Public Defender's Office), in the inland of the state of Rio Grande do Sul, Brazil, in June-August 2015.
The inclusion criteria were guardianship counselors, judges, prosecutors and public defenders who worked with adolescents who use psychoactive substances in Social Assistance and in the Judiciary.The exclusion criteria were to be on leave/ sick leave or on vacation during the period of data collection.
Data wascollected through semi-structured individual interviews that were recorded.The time and place of the interviews were previously scheduled, and the initial guiding questions were How do you perceive the care delivered to adolescents who use psychoactivesubstances in the city?How do you perceive the role of the CAPS AD and its action within the Psychosocial Care Network for Adolescents (RAPS) of the city today?
The length of the interviewsvaried according to the availability of the respondents.Prior to the interview, the respondents read the Free Informed Consent form and signed them in two copies: one for the participant and one for the interviewer.
Subsequently, the interviews were transcribed by the main researcher and content analysis was performed in three steps: Pre-analysis, Material Exploration and Processing of Results, Inference and Interpretation.Pre-analysis consists in the organization of the data to be analyzed; Exploration of material involves careful reading of the material (interview transcripts)for a complete understanding of the content, as well as for the definition of the categories.Treatment of results, inference and interpretation follow with condensation of information for further analysis, culminating in inferential interpretations, and reflective and critical analysis (8) .
In order to comply with the relevant research ethics policies, letter "A" was used to identify the statements made by theSocial Assistantsand "J" was used to identify those made by the participants of the Judiciary.The letters were followed by an Arabic numerals corresponding to the sequence of the interviews (1, 2, 3 ...).The study was approved by the Research Ethics Committee (CEP) with humans under No. 1.074896, according to Resolution No. 466/2012 of Brazil's National Health Council.

RESULTS
Two categories emerged from data analysis: Role of the Psychosocial Care Center Alcohol and other Drugs as perceived by the professionals of the Psychosocial Care Network (RAPS) and Challenges faced by CAPS professionals regarding the delivery of care to adolescents who use alcohol and other drugs.

The role of the Psychosocial Care center Alcohol and other Drugs
According to the respondents, the CAPS is amental health service more focused on treatment/ rehabilitation based on punishment than on prevention/ promotion.However, they acknowledge that the Center facilitates the participation of the family in the care delivered to adolescents.These professionals also believe that the administration of Socio-educational Measures in the treatment of users of psychoactive substances of SPA at a CAPS AD, will lead to a re-signification of the use of psychoactive substances by the adolescents.

In fact, the CAPS does not interfere on compulsory hospitalization, but it becomes involved in the process because the Guardianship Council requests institutionalization, which is then decided by the Judiciary. (A9) The CAPS does not include prevention measures. It only addresses the problem. (A3) The families of the patients must participate in the treatment as much as the bodies involved, because of their central role in the lives of these individuals. (A5)
The socio-educational measure is a kind of "penalty".The adolescent commits a crime, called infraction, and the penalty is a socio-educational measure, which means that these individuals are sentenced to probation or community service.Sometimes it is a protective measure.In such cases, the adolescent is referred to the CAPS to "serve the sentence".(J2)

Challenges in care provided to adolescents by the CAPS Alcohol and other Drugs
Regarding the challenges faced by CAPS professionals in the care of adolescents who use psychoactive substances, the participants mentioned the weaknesses of the service provided.They recognize the impact of infrastructure, human and material resources deficiencies on the care provided.The participants also said that the environment is unattractive for these adolescents, which may impair the follow-up of therapy.Regarding the referral of the adolescents to other inter-sector services, there are difficulties related to the fragmentation of the care network, as well as the poor communication between health service providers, which makes referral and counter-referral difficult.
The adolescents assisted at the CAPS are unable to adhere to the treatment.Why?Because the Center is not prepared to receive them.The staff of the psychiatryunit responsible for theexamination is not available every day of the week,on all shifts.I think the CAPS should to do an active search.They need a strategy that works.This active search should also comprise problems that occur outside the CAPS.(J3) There is lack of vehicles, assistance and staff.(A6).

DISCUSSION
Data analysis shows that the role of the CAPS ADon the care of adolescents that use psychoactive substances is based on treatment/rehabilitation, being characterized as a service that provides intermediate level of care.Psychiatric hospitalization, whether compulsory, voluntary or involuntary, is one possible treatment.However, according to the assumptions of the Brazilian Psychiatric Reform law (4) , institutionalization should be used as a last resort measure when no other extra-hospital interventionsare possible.
The isolationimposed to drug users in some psychiatric treatments contrasts with the recommendations of the Brazilian Health Policy of Integral Care to Users of Alcohol and other Drugs.The history of the policies targeted to the protection of the rights of children and adolescents is characterized by state control over these individuals and the construction of a care model centered on the institutionalization, in order to ensure social protection (9) .
According to one study, despite the Brazilian Psychiatric Reform movement, many professionals still believe that long-term institutionalization is the only way to treat this clientele.It is advocated by many health professionals and disseminated by the media, based on the ideas and beliefs of many drug rehab centers that users of psychoactive substances need hospitalization to "recover" (10) .However, the criminalization of adolescents who use drugs tends to reproduce inequalities.That is, when treatment is focused on punishment, this social group becomes invisible to public investments and visible to repressive and punishment policies (11) .The Brazilian Psychiatric Reform Law (No. 10,216) stresses the importance of changing the model of care to users of psychoactive substances (4) .Thus, a new care model focused on a territorial and family-basedcoordination can be created.The family must be perceived as an open system interconnected with other social structures and other systems that make up society.It is a group of people who share a relationship of care (protection, nourishment, socialization), establish emotional bonds regardless of kinship ties, conditioned by the socioeconomic and cultural values prevailing in a given geographical, historical and cultural context (12) .
According to the respondents, family members play a key role in adolescent care, by supporting and guiding these individuals in a period of major biological and social transformations in their lives.Thus, emotional bonds contribute tothe identification of the problem and support to treatment (13) .
The involvement of family members in the care provided by health servicesimpacts the model of care adopted, as well as the expectations regarding the treatment.This contributes to healthier family relationships, providing a supportive environment that favors treatment adherence and maintenance (14)   .Therefore, new opportunities to improve the treatment of adolescents through socio-educational measures emerge aimed to reduce the use of punishment policies and facilitate social reintegration, in order to strengthen family and community ties (15) .Only after the introduction of the Child and Adolescent Statute (ECA) institutionalizationwas used as a last resort measure and for short periods (2) .Currently, these adolescents are usually institutionalized when they commit infractions, and the process involves sanctions that aresocio-educational measures.However, these measures shall include protection and guarantee of rights, in accordance with the law (15) .
Regarding the challenges involved in the model of care provided to adolescents, poor infrastructure, human and material resources were detected.This aspect corroborates a study that found that lack of support and investments are some difficulties faced by professionals of the CAPS (16) .Thus, it is necessary to plan the interventions targeted to the individuals assisted by the CAPS (17) as recommended by the National Policy on Mental Health that expresses the need for structuring and strengthening health services (4,10) .
In this regard, attractive environments that favor adolescent development according to an integral care model should be provided at the CAPS.This care modelis perceived as necessary toempower the individuals, involving interrelations between users, the community andnature (9) .
The specific and multidimensional demands of this group deserve special attention of the multidisciplinary team (17) .These teams are supposed to implement actions targeted to the empowerment of the adolescents in order to ensure their insertion in the community.Therefore, the first step should be the creation ofa care network (RAPS) that takes into consideration the particularities of each individual and how they perceive themselves (9) .
The activities developed by the RAPS, based on this reference and counter-reference contact, is perceived by the participants as a challenge.The National Mental Health Policy recommends shared care and inter-sector co-responsibility.Therefore, both the management andmultidisciplinary team that provide direct care to these adolescents must observe the recommendations of the referred policy (5) .
The construction of a mental health network of territorial base by the CAPS is crucial to the development of the health system (16) .However, it should involve a multidisciplinary approach and coresponsibility (2) .

FINAL CONSIDERATIONS
This study shed light on the role of a Psychosocial Care Center for Alcohol and Other Drugs on care delivered to adolescents who use psychoactive substances, from the point of view of guardianship counselors and members of the judiciary, as well as on the challengesfaced by these professionals and the care provided to adolescents who use psychoactive substances.
It is believed that this research will contribute to the RAPS and the health services, in order to resignify the welfare practices and to promote the strengthening of these services.
It is suggested that the nursing staff, along with the other health professionalsof the network, develop actions aimed to raise awareness of this population about the effects of the use of substances on physical and mental health, as well as on its impact on family and social relations.Moreover, the State is responsible for reexamining health policies, in order to facilitate the reintegration of these adolescents into society, contributing to their integration, according to the provisions of relevantpublic policies.