ESSAY / ENSAYO / ENSAIO

The protection of children and adolescents from violence: an analysis of public policies and their relationship with the health sector

La protección de los niños y adolescentes contra la violencia: un análisis de las políticas públicas y su relación con el sector salud

Juliane Portella Ribeiro¹; Mara Regina Santos da Silva²; Marta Regina Cezar Vaz³; Priscila Arruda da Silva⁴; Bárbara Tarouco da Silva⁵

¹ RN, Ph.D. candidate. Universidade Federal do Rio Grande (FURG), Brazil. email: ju_ribeiro1985@hotmail.com.

² RN, Ph.D., Professor. FURG, Brazil. email: marare@brturbo.com.br.

³ RN, Ph.D., Professor. FURG, Brazil. email: cezarvaz@vetorial.net.

⁴ RN, Ph.D. candidate. FURG. Brazil. email: patitaarruda@yahoo.com.br.

⁵ RN, Ph.D. candidate, Professor. FURG, Brazil. email: barbaratarouco@yahoo.com.br.

Receipt date: April 25^th 2012. Approval date: September 19^th 2012.

Conflicts of interest: none.

How to cite this article: Ribeiro JP, Silva MRS, Cezar-Vaz MR, Silva PA, Silva BT. The protection of children and adolescents from violence: an analysis of public policies and their relationship with the health sector. Invest Educ Enferm. 2013;31(1): 133-141.

ABSTRACT

In this paper, public protection policies for children and adolescents are analyzed from a health perspective. Interfaces between them, public protection and health policies are presented. Then, the policies are discussed from a conceptual and philosophical viewpoint, also considering the limitations and potentials observed. Findings showed that the strong impact of violence on child and adolescent morbidity and mortality in the Brazilian population has lead to the restructuring of the victim protection network, demanding problem-solving care. Nurses' inclusion in the child and adolescent protection network is fundamental, as these professionals are in a strategic position to identify risks and possible victims.

Key words: violence, nursing, health public policy.

RESUMEN

El artículo analiza las políticas públicas de protección al niño y al adolescente desde la perspectiva de la salud. Se presentan interfaces entre la temática, las políticas públicas de protección y la salud. En consecuencia se abordan las políticas desde los puntos de vista conceptual y filosófico, así como desde las limitaciones y potencialidades observadas. Se encontró que el fuerte impacto de la violencia en la morbilidad y mortalidad de niños y adolescentes, en la población brasileña, produjo la reestructuración de la red de protección de víctimas, para la cual se debieron implementar las condiciones más óptimas a partir de una asistencia resolutiva. La inserción de los enfermeros en la red de servicios de protección a niños y adolescentes fue fundamental, ya que son profesionales que están en una posición estratégica para la identificación de riesgos y posibles víctimas.

Palabras clave: violencia, enfermería, políticas públicas de salud

INTRODUCTION

Violence against children and adolescents has been present throughout humanity's history, posing a serious problem, with consequences for the health and quality of life of the families involved.¹ Its recognition as a public health problem, however, is relatively recent, as is the development of specific public policies and the organization of care and social services for attending these cases. In the 1980's, especially in Brazil, the issue of violence burst onto the program of debates and the area of health planning. Over that decade, there was a qualitative leap in the legislative field, with the promulgation of the new Brazilian Federal Constitution (1988). In Article 227, this articulates that the family and the State shall guarantee children and adolescents, among other rights, life and health, and shall safeguard them from all forms of violence.²

In 1990, the Child and Adolescent Statute (ECA) was approved under Federal Law 8069, of 07/13/1990. This ensures integral protection to the child or adolescent and makes it compulsory to notify the State of suspected or confirmed cases of abuse or mistreatment.³ Following the implementation of the ECA, in quick succession, other proposals were produced to respond to this serious problem, the increasingly high levels of which intensified the concern over children's and adolescents' health. Data from the Childhood and Adolescence Information System (SIPIA), through the compilation of statistics from 1,635 guardianship councils, distributed across fifteen Brazilian states, recorded 174,851 notifications of violations in the period 1999 - 2004. According to these records, family and community co-existence is the right which is violated most, with 51% of notifications, with the categories of ''inadequacy of family co-existence and absence of this co-existence'' being highlighted. Next is the violation of the right to freedom, respect and dignity, with 25% of records, relating to ''acts offensive to the exercising of citizenship and physical, psychological and sexual violence''.⁴ Innumerable studies carried out in varying regions of Brazil have provided valuable contributions to the dimensioning of the problem. Statistics of the cases reported to the Guardianship Councils and programs for attending victimized children and adolescents, in municipalities in the south of Brazil, presented 1,999 recorded cases of violence against children and adolescents in the period 2002 - 2006. Of these, 734 notifications occurred in 2002, and 1,265 in 2006, evidencing an increase in the notifications. Physical violence predominated, followed by neglect and sexual violence.⁵

In spite of the high rates, which depict not only the local situation but the worldwide situation too, it is important to be alert to the fact that the magnitude of the problem of violence against children and adolescents remains uncertain, due to under-reporting, which causes many cases to be excluded from official estimates. These considerations highlight the complexity which surrounds the situation of violence against children and adolescents, especially because they reveal an important dysfunction, not only in the family, but also in the State; at the same time, they allow one to consider that the institutional and social systems attending the families in question are not succeeding in reducing the rates which describe the problem. In the light of the above, the present article analyzes the public policies for the protection of the child and adolescent from the health perspective. Firstly, it presents the interfaces between the issue, the public policies of protection of the child, and health. Sequentially, it focuses on the policies from conceptual and philosophical points of view, and finally looks at the limits and potential of the public policies for protection of the child and adolescent.

Interfaces between violence against children and adolescents, public policies, and health

Violence has become one of the priority problems in public health, due to its magnitude and its repercussions on individuals' health and quality of life. When directed against children and adolescents, it constitutes a serious violation of their rights, to the extent that it denies them freedom, dignity, respect and the opportunity to grow and develop in healthy conditions.¹ From the health point of view, the seriousness of violence in childhood and adolescence has entailed a growing demand for attendance in the public services, precisely in those stages which are crucial to human development.⁶ In Brazil, in the last few years, academics and governmental organs have joined forces in an attempt to care, as effectively as possible, for that tranche of the population which, for a long time, has had its rights and citizenship denied to it. For this reason, the programs and initiatives directed at protecting children and adolescents are increasingly gaining importance with the set of public policies.

The Ministry of Health, through the participation of innumerable departments, has developed actions promoting health and a culture of peace rather than violence. Among these, the National Policy for Reduction of Morbidity and Mortality from Accidents and Violence stands out. Through Ministerial Order GM/MS n° 737, of 05/16/2001, this instituted, within the ambit of the Unified Health System (SUS), the principles and directives for structuring and reinforcing intersectoral actions for preventing violence, for assisting the victims of external causes, and promoting safe and healthy habits and behavior.⁷ The National Program for Opposing Sexual Violence against Children and Young Adults, based in the doctrine of integral protection, seeks to develop varying actions in line with the axes established in the national plan for confronting sexual violence against children and young adults: prevention, defense, accountability, mobilization, articulation and attendance, supporting children and adolescents in situations of personal or social risk.

The National Network of Centers for Prevention of Violence and Promotion of Health (Ministerial Order GM/MS n° 936/2004), implanted in the states and municipalities, coordinated locally by centers for Prevention of Violence and Promotion of Peace, is responsible for articulating and coordinating intersectoral actions promoting health and a culture of peace at the local level.⁸ In ad dition to this, the Unified Health System (Ministerial Order n° 1968/2001) calls for suspected or confirmed cases of mistreatment of children or adolescents attended in the network's services to be notified to the competent authorities.⁹ In line with Brazilian legislation, all forms of infringement of the rights of the child or adolescent are subject to notification, whether they involve physical, psychological or sexual violence, or neglect. This obligation is duly qualified in the Federal Constitution, in the International Convention of the Rights of the Child and Adolescent, in the Child and Adolescent Statute (ECA), and in Brazilian Criminal Law. Article 5 of ECA affirms that no child or adolescent may be the object of any form of neglect, discrimination, exploitation, violence, cruelty or oppression; in the event of transgressing this law, through action or omission concerning the fundamental rights of the child or adolescent in question, the aggressor shall be punished.³

From the health point of view, it is important to stress that innumerable studies carried out have shown that children exposed to violence can present lifelong sequelae: depression, anxiety, suicidal thoughts, post-traumatic stress, aggressiveness, impulsivity, delinquency, hyperactivity, or substance abuse.¹⁰ The long-term effect most reported in the literature is the heightened risk of perpetrating violence in adulthood in the relationship with the victim's own children. The WHO report¹¹ states that there is evidence that the majority of illnesses in adults, including ischemic heart disease, cancer, chronic lung conditions, irritable bowel syndrome and fibromyalgia are related to experiences of violence in childhood. In the same way, Minayo¹² emphasizes the relationship between violence and health, establishing a comparison between the health sector and a drum, on which the results of this phenomenon resonate, and upon which all the injuries and physical, emotional and spiritual traumas produced by society converge. For this, nurses and other health professionals - given that they are frequently the first to be informed about episodes of violence - are in a strategic position to detect risks and identify possible victims.

Although the reason for seeking treatment may, in general, be masked by other problems or symptoms which taken in isolation do not constitute elements for a diagnosis of violence,¹³ it is important for health professionals to be alert not to limit their role to the clinical treatment of the traumas and injuries resulting from these problems. In particular, it is necessary to bear clearly in mind that the children or adolescents, after leaving the place of care provision, are returning to environments where relationships, practices and behaviors remain aggressive.⁹ When cases of violence against children or adolescents arrive in the health services, the victim - in addition to the care specific to this sector - needs services providing psychological, social and legal assistance. Joint work is therefore indispensable, in conjunction with the Childhood and Youth Coordinating Committees, Guardianship Councils and other organs of protection, so as to determine in greater depth the dynamics of the case, its diagnosis and prognosis.¹³

That well-defined mechanisms exist is important not only for detecting cases, but also for access to quality services which are able to respond to the needs of the people involved in the situation of violence - that is, that they can resolve the problems faced by the victims and their families. For this reason, the need is reinforced for the programs and the health services to be linked, multidisciplinary and committed, making it possible for the existing resources to be available, and facilitating access to the support and protection networks.¹⁴

Public policies from the conceptual and philosophical point of view

Violence against children and adolescents, despite having gained greater visibility in recent years, remains difficult to quantify, as it is manifested in variable ways and is not restricted to any specified Brazilian state, region, or city. Hence to understand it one must consider the historical, cultural, economic, legal, political and psychosocial aspects which configure Brazilian society's macro-structure and establish gender, race and power relationships. In addition to these aspects, the diversity of the regions of Brazil which adopt public policies for the protection of the child and adolescent contributes to the use of differing technical methods by professionals in operationalizing actions for confronting violence against the child and adolescent. In the light of this context, it is proposed to work on the concepts which emerge from the discussion of the interfaces of the violence, public policies and health, in order to show philosophical principles which aid in comprehending the phenomenon and, also, in planning actions.

The concept that supports the public policies related to violence against the child and adolescent is that of vulnerability. The present study considers vulnerability in line with the concept proposed by UNESCO: A situation in which the set of characteristics, resources and skills inherent to a given social group are shown to be insufficient, inadequate or difficult to deal with within the system of opportunities offered by society, such that specified social actors may acquire greater levels of well-being or reduce the probability of deterioration of living conditions.¹⁵

Through the analysis of the public policies, it was observed that these are related to the vulnerability of the child and adolescent, and of the family and society in which it occurs. The child and adolescent are considered vulnerable both from the biological and emotional perspectives, given that this is a crucial stage in human development, in which violence can leave definitive marks in their global development. If they are not treated and well-cared-for, the majority may understand violence as a normal practice and reproduce it in their own relationships in the future, becoming aggressors too - these being the values and symbols present in their everyday during the socialization stage of their development.¹⁶

Violence is a polemical subject, principally when one is referring to children and adolescents, as in the large majority of cases it is perpetrated in their homes, by those who while having the duty to bring them up and respect them instead mistreat them, hurt them and abuse them. When violence occurs in the intra-family ambit, it is commonly associated with underprivileged communities. Although it can occur in all social classes, people who are more advantaged socially can rely on more elaborate material and intellectual resources to camouflage the problem - such as private and confidential access to professionals; further, they may explain it in a more accommodating way, reporting it as domestic ''accidents''. Inversely, people belonging to the working classes are denounced with greater frequency, and lacking the financial resources to use private professional services, have to resort to the public health services to help their victims, which leaves them more exposed to society's judgment, as well as clearly showing their vulnerability.¹⁷

In addition to this, in many places in Brazil violence against children and adolescents in the family ambit remains a widespread phenomenon and is accepted as a corrective method for disciplining the behavior of children and adolescents, thus maintaining societal complacency and hindering the control of, and evaluation of the real extent of, the problem. This is because the fact of being considered as something ''normal'' makes notifications rare, meaning that these depict only a small proportion of the incidence of the phenomenon.¹⁷ Thus, some societies become characterized as environments of vulnerability, as is the case with state capitals, metropolitan regions included in the National Public Security Program, major freeway junctions, tourist havens, industrial areas, mining zones, and port areas prioritized by the National Plan to Confront Sexual Violence Against Children and Adolescents.

As violence against children and adolescents can take different forms, it is understood among both health professionals and families from different perspectives, which vary according to the values, beliefs and norms in effect in society, and, consequently, are reflected directly in the notification and denunciation of the cases. The decision to break the pact of silence which applies among the members of a family is generally a dilemma for children and adolescents, as well as for the families, which encounter, on the one hand, feelings of guilt and shame - and on the other, circumstances which impede the denunciation, such as economic and emotional dependency in relation to the aggressor, or having been coerced.

As a result of this, the health professional must be aware that the fact a family is seeking help does not mean that it is in a position to put it into practice, due to the complex effects of the violence on the members' subjectivity and emotional health. It is not the role of the health professional to accelerate this process, nor to try to influence his or her clients' decisions - still less to blame them for retaining practices of violence. Rather, it is to invest in their ability to confront their own problems. Thus the team approach must prioritize guidance and support, such that the victims may better understand the process which they are experiencing and analyze the possible solutions for their problems, taking the decisions which seem most appropriate for their protection.¹³

It also stands out that work with families facing the problem of violence against children and adolescents must be more than simply piecemeal. They must be monitored during a period of time which allows the health professional to evaluate the possibility of the child's return home in safety.¹³ Such a responsibility is a great challenge, as it entails knowing and understanding the family and its dynamics, accepting it as a partner in the care. For that to take place, it is essential to promote networked support so that the family may truly become the qualified key player in the care for the child or adolescent.¹⁸

Limits and potential of public policies for protection of the child and adolescent

The services attending the families must be structured in accordance with the Child and Adolescent Statute (ECA), which, among other aspects, calls for the care policies to be elaborated based on a linked set of governmental and non-governmental actions, prioritizing basic social policies; social work programs and policies; specific services for prevention, and medical and psycho-social care for the victims; and services for identification and localization of parents or guardians.³ The health sector in particular has implemented its own policies, with a national ambit. In recent years, the Ministry of Health (MS), in conjunction with the State and Municipal Health Secretariats, has financed, supported and carried out various actions of vigilance, prevention of violence, and promotion of health and a culture of peace. It falls to the health team to identify organizations and services available in the community that may constitute structures for support or assistance. The integration of these organizations and services permits the process of the actions in a network, making it possible to extend the reach of the interdisciplinary action and to achieve more efficient results.¹⁹ The health professionals who act in the everyday of the health services, however, encounter difficulty in linking the network's services, reflecting a care which is reduced to treating the injuries and to notifying the authorities of cases.

Faced with situations of violence, the health professionals have numerous difficulties, with the notification of cases being one of the main ones, even though it is mandatory. A study seeking to discuss the principal challenges faced by workers in the area of addressing situations of violence indicated the need for greater clarity in the legal conception of the phenomenon and of the suspected cases. It also revealed the need for improvement of the services' infrastructure, for formulation of technical manuals for guidance, and for the publication of more studies on the consequences of the notification of the cases.²⁰

The Ministry of Health recognizes that the shortage of appropriate services of protection, and the undertaking of interventions which are merely piecemeal in attending situations of violence, are obstacles that set back or put off the resolution of the problem. In addition to this, the health professionals who attend the abused children and adolescents often see themselves as isolated in their decision-making, acting in a non-integrated way, in a fragmented network where the various services do not communicate between themselves, missing targets and neglecting the best way of helping. This lack of alignment hinders the joined-up care necessary for an outcome favorable to the protection of the victim, and contributes to the health system re-victimizing the child and/or adolescent, by not guaranteeing their rights and not taking responsibility for the preservation of their life.16 In this regard, it is important for the nurse to know how to recognize a victim in his or her care, and to be aware that the omission can represent an option in the favor of the violence.²¹

Other obstacles met by the health professionals are the lack of knowledge and skills for identifying and attending the victims, in addition to difficulty in notifying and referring the cases to the institutions responsible, and unpreparedness for addressing the aggressors.²² Often, due to not knowing what to do in a serious situation such as, for example, the rape of a child, the health professionals end up taking a position heavily determined by the institutional norms: to the detriment of the immediate needs of the child and the family. In such circumstances, the victim remains unprotected and exposed to the situation, while a long and slow process of providing proof of the situation drags on. In the same way, the absence of intervention can lead to the perpetration of violence, due to the fact of the child's rights being neglected and the child remaining in a circle of silence. For this reason, violence - increasingly present in society's everyday - demands of the health professional the ability to manage such situations in the form of benchmarks which guide the care, making it possible to provide a better resolution of the case.¹⁶ It is also worth noting the weakness of Brazilian services which attend the family unit as a whole and the author of the violence, as this weakens professional action vis-à-vis problems faced by children, adolescents and their families. Interventions prioritizing the family as the focus of attention face structural and economic limitations, allied to a culture of care centered on the individual, which restricts the intervention's scope.²³

In the light of the above, one may observe that professional practice in the situations of violence has shortcomings which compromise the controlling of this problem in the population. In the case of nursing, Costa²⁴ asserts that it does not see itself as an integral and essential part in the management of the cases of violence, and that sometimes to the victims it behaves like a spectator, while on other occasions it seems like a ''case operator'', reducing its practice to the identification of the problem, to ''reception'' in some situations, and always to referral. It is considered, however, that nurses are in a strategic position to detect risks and identify possible victims, given that these normally seek help and treatment for their sufferings in the health services.²⁵ This leads to the possibility of the health professional building links of confidence with the victims and their families, as well as carrying out actions which minimize the suffering.¹⁰

For this, it becomes necessary for nurses to be trained to recognize violence and to care effectively for victims, through a relationship of care which transcends technical actions by establishing links of care with the patient. In addition to this, the care must be planned and based in line with basic instruments of nursing, so as to reflect the public health policies and the existing legislation, so as to promote safety, reception, respect, and satisfaction of the needs of the child and adolescent victims.²⁵ Aiming to support and optimize the accomplishment of the actions of nurses and other health professionals, the Ministry of Health has produced a series of publications, relating to the definitions, norms and protocols for conducts for attending cases of violence against the child or adolescent.14 Thus, it recommends: a) surveying the difficulties faced by municipalities in carrying out actions of identifying and addressing cases of violence against the child and adolescent; b) the development of training projects for professionals involved in attending the victims of violence, thus making it possible to adopt common practices which ensure greater quality to the attendance; c) the creation of mechanisms to share the experience of the professionals within each service, as well as between services and sectors; d) the adoption of actions with an intersectoral perspective, taking into account that the most promising initiatives for confronting violence against children and adolescents are those that not only bring together different areas, but which plan actions in an integrated way at different levels.

Final considerations

Violence's strong impact on the morbidity and mortality of children and adolescents in the Brazilian population has led to the structuring of a network for protecting the victims, which should promote conditions to ensure problem-solving assistance. For this, it is fundamental for nurses to be included in the network for the protection of children and adolescents, being in a strategic position to identify risks and possible victims. Nursing in particular, through its insertion in different levels of the health sector and the actions that make up its work process, has wide possibilities for intervening in cases of violence. To this end, nurses, as caregivers and educators, become involved in acting politically in care for children, adolescents and families involved in situations of violence, so as to minimize their suffering and improve their quality of life. Thus, training environments must also include questions related to the issue of violence in their curriculum, such that access to services and their power to resolve issues may become reality at all levels of care, contributing, as a consequence, to the offering of qualified care, based in an ethical position and satisfactory to their users.

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