GENDER, RACE AND ‘EXTERNALIZING PROBLEMS’ IN A CHILD MENTAL HEALTH SERVICEABSTRACT
This study aimed to characterize the profile of children who presented complaints involving ‘externalizing problems’ in a child mental health service located in Salvador, state of Bahia. Based on the follow-up records of 97 patients who attended the service in 2018, the following variables were analyzed: age, sex, race/color, main complaint, family configuration, main companion, source of referral, and school complaint. Data were organized in a spreadsheet with the collected variables and subjected to simple statistical analysis, including the identification of frequencies and the crossing of some variables. The results show differences in the proportion of externalizing problems linked to sex, race/color, and school complaint variables. Most children are black (71.14%), male (70.10%), and aged between 4 and 9 years (61.85%). Complaints involving externalizing problems were brought in relation to 54.42% of the boys, 31.03% of the girls, 56.41% for black children, 56.67% for brown children, and 40% for white children. Attention is drawn to the high frequency of school complaints related to children who presented externalizing problems and the higher proportion of school complaints among black children compared to brown and white children. The results reiterate some findings from previous studies, such as gender differences, and innovate by bringing some relationships with race/color and school complaints. The need to deepen this focus in new studies aimed at strengthening non-sexist and anti-racist health practices is highlighted.
Keywords:
Child mental health; gender; race
RESUMO
Este estudo visa caracterizar o perfil de crianças que apresentaram queixas envolvendo ‘problemas externalizantes’ em um serviço de saúde mental infantil situado em Salvador, Bahia. Com base nas fichas de acompanhamento das 97 crianças que frequentaram o serviço em 2018, as seguintes variáveis foram levantadas: idade, sexo, raça/cor, motivo de procura, arranjo familiar, principal acompanhante, procedência de encaminhamento e queixa escolar. Com as variáveis levantadas, os dados foram organizados em uma planilha e submetidos à análise estatística simples incluindo a identificação de frequências e o cruzamento de algumas variáveis. Os resultados mostram diferenças na proporção de problemas externalizantes vinculadas às variáveis sexo, raça/cor e queixa escolar. A maioria das crianças é negra (71,14%), do sexo masculino (70,10%), com idade entre de 4-9 anos (61,85%). Foram trazidas queixas envolvendo problemas externalizantes para 54,42% dos meninos e 31,03% das meninas e para 56,41% das crianças pretas, 56,67% das crianças pardas e 40% das crianças brancas. Chama a atenção a alta frequência de queixas escolares relacionadas às crianças que apresentaram problemas externalizantes e a maior proporção de queixas escolares entre crianças pretas quando comparadas às crianças pardas e brancas. Os resultados reiteram alguns achados de estudos anteriores, como as diferenças de gênero, e inovam ao trazer algumas relações com raça/cor e queixa escolar. Destaca-se a necessidade de aprofundar este recorte em novos estudos visando o fortalecimento de práticas de saúde não sexistas e antirracistas.
Palavras-chave:
Saúde mental infantil; gênero; raça
RESUMEN
Este estudio buscó caracterizar el perfil de los niños que presentaron quejas relacionadas con ‘problemas de externalización’ en un servicio de salud mental infantil ubicado en Salvador, Bahia. Con base en los registros de acompañamiento de los 97 niños que asistieron al servicio en 2018, se plantearon las variables: edad, sexo, raza/color, motivo de búsqueda, configuración familiar, acompañante principal, origen de la derivación y queja escolar. Con las variables planteadas, los datos se organizaron en una hoja de cálculo y se sometieron a un análisis estadístico simple que incluyó la identificación de frecuencias y el cruce de algunas variables. Los resultados muestran diferencias en la proporción de problemas de externalización vinculados a las variables sexo, raza y queja escolar. La mayoría de los niños son negros (71.14%), varones (70.10%) y tienen de 4 a 9 años (61.85%). Se presentaron quejas relacionadas con problemas de externalización en el 54.42% de los niños y el 31.03% de las niñas y para el 56.41% de los niños negros, el 56.67% de los marrones y el 40% de los blancos. Se destaca la alta frecuencia de quejas escolares relacionadas con niños que tuvieron problemas de externalización y la mayor proporción de quejas escolares entre niños negros en comparación a los niños marrones y blancos. Los resultados reiteran algunos hallazgos de estudios previos, como las diferencias de género, e innovan al mostrar relaciones con la raza y las quejas escolares. Se destaca la necesidad de profundizar este enfoque en nuevos estudios, con el objetivo de fortalecer las prácticas de salud no sexistas y antirracistas.
Palabras clave:
Salud mental infantil; género; raza
Introduction
Not only in Brazil but also in several other countries around the world, there is a huge gap between the need for mental health care for children and adolescents and the existence of a network of public health policies to meet this demand (Couto, Duarte, & Delgado, 2008). In Brazil, there was a late inclusion of child and adolescent mental health in the public health policy agenda as well as the Psychiatric Reform (Couto & Delgado, 2015).
If, previously, assistance to the child and youth population was restricted to the spheres of social assistance, education, and philanthropy, with redemocratization, new modalities of care begin to take shape (Taño & Matsukura, 2015). Such transformation was only possible due to a change in the conception of children and adolescents, who are now perceived as subjects prone to psychological suffering with the right to care that is not “[…] reduced to the correction, normalization or adaptation of behaviors” (Couto & Delgado, 2015, p. 22).
The creation of Psychosocial Care Centers (CAPS) in 2001 and, two years later, the CAPSi modality, aimed at children and adolescents with conditions considered severe and persistent, marks the implementation of these new care modalities (Taño & Matsukura, 2015). The Psychosocial Care Network (RAPS) also has Primary Care, considered the gateway to the Unified Health System (SUS), and school clinics. However, procedural care for mental health is still little present in Primary Care (Rangel, Bustamante, & Silva, 2015; Bustamante, Oliveira, & Rodrigues, 2017).
Thus, despite considerable advances, it is still a challenge to establish an integrated network of mental health services and actions in municipalities, especially when it comes to the child and youth population. To fill the care gap left by the specific coverage of CAPSi and the lack of procedural assistance to mental health through Primary Care devices, the research, teaching, and extension project ‘Brincando em família’ seeks to be part of the child care network of the municipality of Salvador, state of Bahia.
Linked to the Psychology Institute of the Federal University of Bahia (UFBA), this project acts as a mental health service aimed at children and their families, integrating theoretical contributions from psychoanalysis with the principles of psychosocial care (Bustamante et al., 2017). Operating twice a week in two shifts, the service relies on a team made up of psychologists and psychology undergraduates. It is a collective and welcoming space located in a public library, with playing as the main form of interaction and listening.
User characterization studies have proven important tools for rethinking mental health practices, as they allow us to better understand the attending population and the reality of different services (Santos, 2006). In child mental health services, several studies (Santos, 2006; Bolsoni-Silva, Paiva, & Barbosa, 2009; Rangel et al., 2015; Nakamura, Plance, & Ehrenberg, 2018; Ceballos, Santos, & Mota, 2016) demonstrate that ‘externalizing problems’ are the most frequent complaints and there is a predominance of male children attending services, who, in general, present more ‘externalizing problems’ compared to female children.
Although there is no consensus on how to classify complaints or reasons for seeking, many characterization studies adopt the nomenclature ‘externalizing problems’ to refer to complaints such as aggression, agitation, disobedience, and delinquency. These comprise, alongside internalizing problems (such as depression, anxiety, and withdrawal), the definition of behavioral and emotional problems (Lins, Alvarenga, Paixão, Almeida, & Costa, 2012).
Complaints or reasons for seeking are understood in the literature not as a diagnosis but as the reason that led the child and their family to seek professional help. As psychoanalyst Michele Roman Faria (1998) explains, the clinic with children has a particular feature: the initial demand comes from adults and institutions (caregivers, education professionals, among others) who speak for the child, locating a symptom in them. Therefore, it is always a ‘subjective perspective’ (Faria, 1998) that does not always correspond to what the child expresses about themselves.
Some studies also point to the increasing arrival, through school referral, of children and adolescents to health devices with complaints regarding learning and/or behavioral problems (Beltrame & Boarini, 2013; Beltrame, Gesser, & Souza, 2019), where they are treated from a medicalizing and individualizing perspective in a care process in which the school is rarely involved (Beltrame & Boarini, 2013).
As Silva, Barros, Azevedo, Batista and Policarpo (2017) point out, an element that draws attention not because of its presence but because of its absence in characterization studies is the issue of race/color. In this sense, a survey by Ceballos et al. (2016) in different CAPS in Salvador, state of Bahia, observed that only one service had consistent records of the race/color variable.
Another variable that caught our attention was gender, which, although present in many articles, was rarely included in discussions and reflections. This gap is pointed out by Muylaert, Delfini and Reis (2015) who, based on a study carried out in several CAPSi in the state of São Paulo, state that care practices for people in psychological distress are not equally distributed; the responsibility is up to women. Often, these women are subject to dual roles, as they are responsible for the household income as well as caring for the children.
Considering what has been exposed so far and the importance of knowing the attended population to reflect on mental health practices, the objective of this study was to characterize the children and their families who attended the Brincando em família project in 2018. Bearing in mind the gaps raised, we developed reflections on the complaints of ‘externalizing problems’ in their intersection with issues of gender, race, and school complaints.
Method
The present study used a mixed methodology. This is a descriptive investigation, quantifying the object studied, from which some general reflections are developed (Creswell, 2010).
We analyzed the monitoring records, which contain data on the children and their families filled out on the day of arrival at the project, corresponding to the 97 children who arrived at the project in 2018 and who agreed to participate in the study. There were no refusals to participate in the research or a prior selection of families included in the present study.
Data were collected on the variables: age, sex, race/color, reason for seeking, family configuration, main accompanying adult, referral source, and school complaint. If any information was not included in the form, reports of the family’s initial care were used, which are produced weekly by those in charge of the project. With the variables identified, data were organized in a spreadsheet and subjected to simple statistical analysis, including the identification of frequencies and the crossing of some variables.
For this study, we considered a reason for seeking what is verbalized by the adult upon arrival at the project. It is also possible to attend the project without presenting any demands regarding the child, which is part of the health promotion proposed by the service in question. The reasons for seeking were classified following the proposal of Rangel et al. (2015).
For this survey, in dialogue with Beltrame and Boarini (2013), referrals and complaints from the school regarding the initial complaint brought by those responsible concerning the children were considered school complaints.
Regarding family configurations, we take the understanding of Rangel et al. (2015) that a family constitutes a group whose members (blood or non-blood) reside in the same household, as well as the classification used by the aforementioned authors.
As for the category of race, here, it is “[…] a social construction that produces meanings in people’s daily lives, and that engenders and maintains profound material and symbolic inequalities” (Schucman, 2018, p. 32), and, in Brazil, it is constructed from phenotypic characteristics, such as skin color, the shape of the nose, lips, and hair. Until 2019, the race/color question was completed by heteroclassification, based on phenotypic characteristics observed by the professional when initially welcoming the family. This was changed to self-declaration by the guardian and the child when possible. Throughout the article, we adopted the IBGE racial categories (black, brown, white, yellow, and indigenous) and used the category ‘black’ when talking about black and brown people together, as proposed by the Brazilian black movement (Piza & Rosemberg, 1999).
The research project that gave rise to the present study was approved by the Research Ethics Committee of a unit of the Federal University of Bahia (Opinion 120.687).
Results
Of the 97 children who reached the service in 2018, 29.89% were female, and 70.10% were male. The age group that most concentrated children was four to six years old (36.08%), followed by seven to nine years old (25.77%). In the distribution by family configuration, families with a conjugal nuclear configuration (including reconstituted ones) represented 44.71%. Next are single-parent and extended families, with 25.88% each, and only 3.53% of children are raised by their grandparents. Although the conjugal nuclear family configuration is, among the configurations, the one with the highest number, more than half (55.29%) of the children were in ‘unconventional’ configurations, illustrating the diversity of families that arrive at the project. In general, they are predominantly low-income, black families and residents of popular neighborhoods in different areas of the municipality. It is common for families to receive some type of government assistance, such as Bolsa família, elderly pensions, or Continuous Payment Benefit (BPC).
Regarding how they reached the project, 63.53% of families were referred by other services; 28.23% came as a recommendation from other attendees or after obtaining information about the project on social media; 8.24% were sent directly by the school. Most children (59.79%) arrived accompanied by their mothers (biological or not), followed by another female family member, such as an aunt, grandmother, and great-aunt (13.40%). In 10.31% of cases, the child was accompanied by the mother and father, while only 6.19% of children had the father as the main accompanying adult. Adding up the cases in which the woman was present as the main accompanying adult, in 82.47% of families, the person responsible for accompanying the child at the service was a woman.
With respect to the reason for seeking the project, most children (85.57%) arrived with a complaint. Among children with complaints (83), externalizing problems, with emphasis on aggression, made up more than half (55.41%) of the reason for seeking the project. Next are internalizing problems (13.25%), learning difficulties (10.84%), developmental difficulties (9.63%), others (8.43%), and, finally, the need for socialization (2.40%).
When looking at the relationship between the complaint and the child’s sex, more than half of the boys (54.42%) had externalizing problems, and only 31.03% of the girls had the same complaint. When it comes to internalizing problems, the frequency was proportionally higher among girls (27.59%) than boys (4.41%).
Regarding the race/skin color variable (Table 1), of the 97 children, 39 (40.21%) were black, 30 (30.93%) were brown, and 15 (15.46%) were white. In 13 cases, the color was not included (13.40%). By crossing data on race/skin color and reason for seeking, of the 46 children with complaints of aggressiveness and externalizing problems, 22 (47.83%) were black, 17 were brown (36.96%), six were white (13.04%), and one had no information. Thus, data show a higher proportion of black and brown children with externalizing problems than the general distribution of children by race/skin color.
distribution according to the relationship between reasons for seeking and race/skin color
As for the school complaint variable, half (50.60%) of the children who arrived at the project with a specific demand had received a school complaint. Of these 42 children with school complaints, 30 (71.43%) had externalizing problems, and 12 (28.57%) brought other complaints. Among the children who did not receive a school complaint, 14 (36.84%) had externalizing problems, while 24 (63.16%) had other complaints. Thus, children with externalizing problems received more school complaints than children with other complaints.
Finally, the variables of school complaints and race/skin color were also related. As seen in Table 2, among black children, around 59% had received a school complaint, while 38.46% had not. Among brown children, around 41% had school complaints and 55% did not. Among white children, around 43% received a school complaint, while half - (50%) - did not. Therefore, among white and brown children with some type of complaint, more children did not receive a school complaint than those who did. This trend was not found among children declared as black, among whom there were more children with school complaints than without.
Discussion
Considering the data presented, there were points of agreement with other characterization studies: a higher number of externalizing problems than other complaints (Santos, 2006; Bolsoni-Silva et al., 2009; Rangel et al., 2015; Nakamura et al., 2018), the predominance of male children (Santos, 2006; Rangel et al., 2015; Ceballos et al., 2016; Nakamura et al., 2018), and the higher frequency of ‘externalizing problems’ among boys than girls (Santos, 2006; Rangel et al., 2015; Nakamura et al., 2018).
The findings highlight important differences in terms of gender. Here, we take the definition of gender by Judith Butler (2017, p. 242), for whom gender is a “[…] stylized repetition of acts […]”, with ‘acts’ being repeated performances that are, at the same time, re-enactment and new experience of pre-established meanings of what it means to be a ‘man’ or ‘woman’. This set of performative practices (acts, gestures, and performances) constructs the illusion of a stable and essentialist gender identity, enforcing a dual and hierarchical conception of the place of men and women (Butler, 2017). Butler also points to the inseparability of gender from other categories, such as race, class, and sexuality, with which it is in constant intersection in a given space-time.
Cláudia Pons Cardoso (2014), in the light of thinker Lélia Gonzalez, states that, in Brazil, race and sexism are structuring axes of oppression, which causes race to reshape the experience of gender and vice versa. According to the author, “[…] gendered racism produces particular experiences for women from racially subjected groups” (Cardoso, 2014, p. 975).
In turn, Osmundo Pinho (2004, p. 65) argues that ‘man’ himself is an “[…] artifact of gender structures […]”, not a monolithic, static, and universal category. In this way, just as black feminism destabilized what was understood as ‘woman’, studies that focus on thinking about masculinity point to the different masculinities that exist throughout history and cultures. Pinho (2004) also talks about hegemonic masculinities (which, in the case of Brazil, would be the white, cisgender, heterosexual, upper-class men) and subaltern masculinities (being black, gay, transgender, and poor men).
In dialogue with the contributions of Judith Butler, Brazilian researcher Valeska Zanello (2018) weaves an important discussion about gender and mental health by proposing that there are privileged paths of subjectivation for men and women produced through what she calls ‘gender dispositifs’. These are defined by the author, based on the philosophers Giorgio Agamben and Michel Foucault, as practices, discourses, and knowledge that capture, guide bodies and construct subjectivities.
The ‘efficacy dispositif’ is the means by which men subjectify themselves, in which ‘sexual and labor virility’ are two important identity anchors. The first concerns the construction of man as an active, impenetrable sexual eater, in which other masculinities are subjugated; the second refers to the construction of men as providers for the family, with work as an important pillar of identity. Virility, therefore, involves the belief that it is necessary to toughen up to be ‘truly a man’, having control over oneself, one’s emotions, women, and also other masculinities (Zanello, 2018).
Women, according to Zanello (2018), subjectify themselves based on ‘loving and maternal dispositifs’. For this work, only the second will be discussed. The ‘maternal dispositif’ arises from the historical construction that women, because they have the reproductive capacity in their bodies, are naturally good, maternal, and available to care, associating care as an ‘essentially’ feminine task. It is necessary to emphasize that the social markers of race, class, and sexuality make subjects constitute themselves based on these ‘dispositifs’ in different ways, which we will see later with a focus on the race category.
In this way, dispositifs construct, through repeated performances, distinct ‘identity pillars’ for men and women, which, when called into question, can generate psychological suffering (Zanello, 2018). Still, according to the author, an important factor of the dispositifs are gender technologies, such as media, cinema, toys, games, swearing, and children’s books, which contribute to the production of an ‘affective pedagogy’, that is, ways in which women and men should feel and express feelings (Zanello, 2018).
Butler (2017) and Zanello (2018), as well as Cardoso (2014) and Pinho (2004), help us think about how subjectivity is engendered within countless power relations. Although the authors are not talking directly about children, it is in this direction that we believe in thinking about the gender differences found in the present study, looking at complaints from a social perspective.
Interactions with gender norms happen from an early age and are socialized within the family in the daily care of little ones. According to Butler (2017), the repetitions of pre-established norms of what it means to be a man or a woman also affect children, located, for example, in the prescriptions of how boys and girls should behave, play, dress, and even feel. Zanello (2018) brings as an example that while girls are approved of a specific form of aggressiveness, expressed through self-aggression and crying, boys are more allowed and even encouraged the aggressiveness directed ‘outwards’.
Based on this reflection, the predominance of male children attending mental health services does not necessarily mean that they suffer more than girls but that they suffer and present symptoms in different ways. As we have seen, part of the construction of ‘being a girl’ is a more silent form of suffering, which can have the effect of not disturbing the environment to the point of seeking professional help. It is in this sense that we can also think about the higher frequency of internalizing problems (such as fear, isolation, and sadness) in girls than boys. The higher frequency of externalizing problems, especially aggression, among boys is related to a more permitted and even encouraged form of expression, forming part of the very construction of a certain masculine virility, which is an expression of the efficacy dispositif (Zanello, 2018). It is worth remembering that these are facilitated pathways in culture, which does not mean that there cannot be girls who ‘externalize’ and boys who ‘internalize’.
The gender perspective is also necessary when we look at the overwhelming number of women (82.47%), mostly mothers, accompanying the children in the project in question, even when more than half of the children live with their father or stepfather. This result takes us, on the one hand, to the maternal dispositif (Zanello, 2018), in that there is the reproduction of care as a naturally feminine activity, even in conjugal families in which a man is present; on the other, the maintenance of the figure of man as worker and provider, an expression of the labor efficiency dispositif.
In this way, the sexual division of labor is still strongly present but with important detail, as in the study by Muylaert et al. (2015), which deals with low-income women and mothers who also provide for the household and are often heads of their families. In Brincando em família, the majority are black women, who, according to philosopher Sueli Carneiro (2019), are historically subjected to multiple working hours. Thus, following what Cardoso (2014) proposes, that it is not possible to separate gender from other categories of oppression, it is necessary to highlight something that Zanello (2018) points out, namely, that to black and low-income women, which is the case of the population attending the service in question, the role of caregiver is even more naturalized. They take care of their own home, their children, and often other people’s homes without having the possibility of receiving care, in addition to historically having had to provide for their families (Zanello, 2018). This overload can lead to physical and emotional exhaustion.
Another aspect that drew attention was the racial differences in the data. As we have seen, black children - including those perceived as black (40.21%) and brown (30.93%) - comprise 71.13% of the total number of children, 15.46% were white, and 13.40% had no information. Thus, among the children, we have a predominant profile of boys, between four and nine years old, black, and low-income. To better situate the racial distribution in the project, it is necessary to remember that, in Salvador, 36.5% of the population declared themselves black, 45.6% mixed race, 17.1% white, and 0.8% other in a survey carried out by IBGE in 2017 (Fernandes, 2019). Thus, Salvador has a black population that reaches 82%.
Although the racial theme has been increasingly recognized as a fundamental element in thinking about inequalities in Brazil, including those concerning health/disease processes, the race/color variable remains largely absent from user records on mental health devices (David, 2018; Silva et al., 2017). The incompleteness and/or lack of racial registration means that, according to David (2018), race is a ‘shadow variable’, making the understanding of health demands in their racial particularities invisible.
Schucman (2018) points out that race, as a social category, produces the phenomenon of racism by classifying and hierarchizing groups, granting, in the Brazilian case, privileges to the white population to the detriment of the black population. Psychoanalyst Isildinha Baptista Nogueira (2017) discusses in her text some representations of the black body amid a society whose ideal of whiteness is imposed. While, in a hegemonic discourse, the white signifier is linked to virtues, to what is beautiful, civilized, and universal, the black signifier is associated with that which is dirty, derogatory, barbaric, and the ‘other’. Following this logic, Nogueira (2017, p. 123) asks: “If what constitutes the subject is the gaze of the other, what about the black person who is confronted with the gaze of the other, who shows that they recognize in them the meaning that black skin brings as a signifier?”. Given this view, according to the author, the black person would be left with the desire to refuse these pejorative meanings by denying themselves and their bodies, a process that can generate intense psychological suffering.
Bringing this discussion to childhood, Maria Lúcia da Silva (2017) says that such representations can exert harmful influences on the psyche of black children by giving them a negative view. In the case of many children, as the author points out, it is possible that the first experiences of discrimination and prejudice were experienced at home, from the perspective of caregivers, and later, also at school, a privileged place for the socialization of young children.
We will now return to the data collected in light of the theoretical reflection presented. As we saw, in addition to the greater presence of black people in the project, we found a higher proportion of externalizing problems related to black and brown children. Among black and brown children, black children presented proportionally more externalizing problems. Furthermore, as the authors Beltrame and Boarini (2013) show, in the face of behaviors considered undesirable, such as aggressiveness and restlessness, the school has acted in a way that delegates the fight against it to health institutions. This can also be seen in Brincando em família, where data showed that a little more than half (50.60%) of the children who came to the project with a specific demand had received school complaints, which were mainly related to ‘externalizing problems’.
Furthermore, we also observed a higher proportion of school complaints associated with black children than with white children. However, when looking at black and brown children separately, the proportion of black children with school complaints is higher than those without complaints, and when we look at brown children, those who did not receive a school complaint are in a higher proportion, a distribution also observed among white children.
Given the data presented, we decided to outline reflections on two fronts, which would need to be further explored in future studies. On the one hand, we think that the higher frequency of externalizing problems in black children may be related to the expression of discomfort caused by racism, a form of expression that is also constructed, as we saw previously, from ‘male virility’ in the case of boys. If virility is already configured as an important identity anchor in male gender performances (Zanello, 2018), Deivison Faustino Nkosi (2014) points to the even more central place that the expression of virility can have for gender affirmation of ‘being a man’, in the case of black masculinities. In dialogue with authors such as Frantz Fanon, Nkosi (2014) points out how, in former slave societies, the affirmation of virility through aggressiveness can be understood as a reaction to the condition of racial subordination.
In this way, crossed by the meanings hegemonically attributed to the black body, whether through racist comments (from peers or adults), looks, or from the unspoken, such as not seeing their body represented in films, children’s stories, television, and didactic books, children can find in these complaints - aggression, disobedience, and agitation - a way of expressing their suffering. A suffering that is also gendered and racialized.
On the other hand, when thinking about externalizing problems as complaints attributed to children by adults, therefore having to do with how the child is viewed, we question whether less tolerance is at stake concerning aggressive manifestations, disobedience, and agitation in black children. As Lins et al. (2012) explain, the so-called ‘externalizing problems’ are targets of greater attention and mobilization because they are considered undesirable and uncomfortable. Added to this, as previously explained, certain meanings such as barbaric, less intelligent meanings, among others, were historically attributed to black people. As Pinho (2019, p. 107) writes, “Violence and the stigma of barbarism and savagery are united [...] with the symbolic space of the representation of black male identity”. Thus, given the high number of school complaints related to externalizing problems in black boys, we question whether manifestations of aggression, disobedience, or agitation coming from black and low-income children are perceived by the school in a way that is more loaded with negative representations linked to black masculinities, making these behaviors less tolerated and perceived as a ‘problem’.
When referred to health institutions, the child and their family, but especially the child, are held responsible and blamed for their difficulty, placing the school itself in a blind spot (Beltrame & Boarini, 2013; Beltrame et al., 2019). According to Beltrame et al. (2019, p. 3), by only treating the child individually, as if they were the cause of their ‘problem’, “[…] the entire social and political context that constitutes the legitimations and controversies regarding these supposed disorders […]” is excluded. This reinforces normalization and disciplinary practices that go against the psychosocial perspective proposed by psychiatric reform.
Therefore, we highlight the importance of proposing co-responsible care with the different actors present in the child’s life, including the school, to be able to listen, as Faria (1998) says, to the different ‘subjective aspects’, and making the ethical effort of separating the symptom attributed to the child by adults from the symptom the child expresses about themselves. We also emphasize the importance of discussing with the family and school how to look at these behaviors that are considered uncomfortable and think together about practices that go against the individualization and medicalization of demand. After all, in addition to the child responding, based on their symptom, to what is symptomatic in the family structure (Faria, 1998), they also denounce what is symptomatic in the network of relationships in which they are inserted in a broader way, including the school and society in their intersections with social markers.
Final considerations
In this study, we sought to characterize the profile of children and their families who attended the children’s mental health project Brincando em família in 2018. Some points poorly explored in the literature could be elucidated, such as the inclusion and discussion of racial and gender variables and school complaints. The work faces, however, some limits, such as the small number of the total population and the artisanal way in which the data was collected. The discussion of racial themes is also under construction in the project. In the year in which the data for this study were produced, the project was still working with racial heteroclassification, using as a criterion the phenotype according to the perception of the person in charge of the first reception to the family, a behavior that has already been changed.
In this article, we present a possible way of understanding complaints under the name ‘externalizing problems’, which does not mean exhausting their understanding. By focusing on broader and more structural movements, we focused on the need to understand complaints related to children by integrating gender and race, indicating the importance of constructing interventions that are receptive to the social production of suffering and complaints. We highlight, in particular, the need for greater depth in future studies on black masculinities and their relationship with mental health.
To reflect on the uniqueness of each case and management possibilities, the service in question has also been dialoguing with contributions from psychoanalyst Donald Winnicott, for whom aggressiveness and the management of the environment about this are fundamental in the child’s emotional development. Reflection on this point has already been developed elsewhere (Bustamante, 2020).
With regard to mental health care practices for children in the services, we highlight the importance of filling out the race/color in users’ files, as well as including toys and games that value blackness and that do not naturalize gender roles. Furthermore, professionals must listen carefully to how children and their families interact, in their uniqueness, with social determinants, such as gender, race, class, and also sexuality, interactions that can produce suffering. This will definitely require self-criticism and repositioning on the part of services. Finally, we highlight the need to deepen this focus in new studies aimed at strengthening non-sexist, anti-racist health practices that go against the grain of normalization, disciplinarization, and medicalization of children.
References
-
Beltrame, M. M., & Boarini, M. L. (2013). Saúde mental e infância: reflexões sobre a demanda escolar de um CAPSi.Psicologia: Ciência e Profissão , 33(2), 336-349. https://dx.doi.org/10.1590/S1414-98932013000200007
» https://doi.org/10.1590/S1414-98932013000200007 -
Beltrame, R. L., Gesser, M., & Souza, S. V. de(2019). Diálogos sobre medicalização da infância e educação: uma revisão de literatura.Psicologia em Estudo , 24, e42566.https://doi.org/10.4025/psicolestud.v24i0.42566
» https://doi.org/10.4025/psicolestud.v24i0.42566 -
Bolsoni-Silva, A. T., Paiva, M. M., & Barbosa, C. G. (2009). Problemas de comportamento de crianças/adolescentes e dificuldades de pais/cuidadores: um estudo de caracterização.Psicologia Clínica , 21(1), 169-184. https://doi.org/10.1590/S0103-56652009000100012
» https://doi.org/10.1590/S0103-56652009000100012 -
Bustamante, V. (2020). Cuidado a crianças e suas famílias e queixas de agressividade: um estudo de caso clínico.Psicologia Clínica , 32(1), 15-34. https://dx.doi.org/10.33208/PC1980-5438v0032n01A01
» https://doi.org/10.33208/PC1980-5438v0032n01A01 - Bustamante, V., Oliveira, R., & Rodrigues, N. B. (2017). Acolhida e cuidado a crianças e famílias em um serviço de saúde mental infantil. Psicologia Clínica, 29(3), 429-447.
- Butler, J. P. (2017). Problemas de gênero: feminismo e subversão da identidade (R. Aguar, trad.). Rio de Janeiro, RJ: Civilização Brasileira. Obra original publicada em 1990.
-
Cardoso, C. P. (2014). Amefricanizando o feminismo: o pensamento de Lélia Gonzalez. Estudos Feministas, 22(3), 965-986. https://doi.org/10.1590/S0104-026X2014000300015
» https://doi.org/10.1590/S0104-026X2014000300015 - Carneiro, S. (2019). Enegrecer o feminismo: a situação da mulher negra na América Latina a partir de uma perspectiva de gênero. In H. B. Hollanda(Org.), Pensamento feminista: conceitos fundamentais (p. 313-321). Rio de Janeiro, RJ: Bazar do Tempo.
-
Ceballos, G. Y., Santos, D. N., & Mota, E. L. A. (2016). Atendimento infanto-juvenil em Centros de Atenção Psicossocial de Salvador, Bahia, Brasil. Revista Baiana de Saúde Pública, 40(3), 648-664.https://doi.org/10.22278/2318-2660.2016.v40.n3.a1885
» https://doi.org/10.22278/2318-2660.2016.v40.n3.a1885 -
Couto, M. C. V., & Delgado, P. G. G. (2015). Crianças e adolescentes na agenda política da saúde mental brasileira: inclusão tardia, desafios atuais. Psicologia clínica, 27(1), 17-40. https://doi.org/10.1590/0103-56652015000100002
» https://doi.org/10.1590/0103-56652015000100002 -
Couto, M. C. V., Duarte, C. S., & Delgado, P. G. G. (2008). A saúde mental infantil na saúde pública brasileira: situação atual e desafios.Revista Brasileira de Psiquiatria , 30(4), 384-389. https://doi.org/10.1590/S1516-44462008000400015
» https://doi.org/10.1590/S1516-44462008000400015 - Creswell, J. W. (2010). Projeto de pesquisa: métodos qualitativo, quantitativo e misto (3a ed). Porto Alegre, RS: Artmed.
-
David, E. de C. (2018). Saúde mental e racismo: a atuação de um Centro de Atenção Psicossocial II Infantojuvenil (Dissertação de mestrado). Programa de Estudos Pós-Graduados em Psicologia Social, Pontifícia Universidade Católica, São Paulo. Recuperado de:https://tede2.pucsp.br/handle/handle/21029
» https://tede2.pucsp.br/handle/handle/21029 - Faria, M. R. (1998). Introdução à psicanálise de crianças: o lugar dos pais São Paulo, SP: Hacker Editores.
-
Fernandes, F. B. M. (2019). Dados do IBGE, mandato do vereador Silvio Humberto Recuperado de: http://generoesexualidade.ffch.ufba.br/dados-do-ibge-mandato-do-vereador-silvio-humberto/
» http://generoesexualidade.ffch.ufba.br/dados-do-ibge-mandato-do-vereador-silvio-humberto/ - Lins, T., Alvarenga, P., Paixão, C., Almeida, E., & Costa, H. (2012). Problemas externalizantes e agressividade infantil: uma revisão de estudos brasileiros.Arquivos Brasileiros de Psicologia , 64(3), 59-75.
-
Muylaert, C. J., Delfini, P. S. S., & Reis, A. O. A. (2015). Relações de gênero entre familiares cuidadores de crianças e adolescentes de serviços de saúde mental. Physis: Revista de Saúde Coletiva, 25(1), 41-58. https://doi.org/10.1590/S0103-73312015000100004
» https://doi.org/10.1590/S0103-73312015000100004 -
Nakamura, E., Planche, M., & Ehrenberg, A. (2018). The social aspects in the identification of children’s mental health problems in two health services in Paris, France.Interface - Comunicação, Saúde, Educação , 22(65), 411-422. https://doi.org/10.1590/1807-57622016.0911
» https://doi.org/10.1590/1807-57622016.0911 - Nkosi, D. F. (2014). O pênis sem o falo: algumas reflexões sobre homens negros, masculinidades e racismo. In E. A. Blay (Coord.), Feminismos e masculinidades: novos caminhos para enfrentar a violência contra a mulher(1a ed., p. 75-104). São Paulo, SP: Cultura Acadêmica.
- Nogueira, I. B. (2017). Cor e inconsciente. In N. M. Kon, M. L. Silva, & C. C. Abud (Orgs.), O racismo e o negro no Brasil: questões para a psicanálise (1a ed., p. 121-126). São Paulo, SP: Perspectiva.
-
Rangel, L. C. C., Bustamante, V., & Silva, G. B. (2015). Caracterização da população de um serviço de saúde mental infantil em Salvador.Psicologia Em Estudo , 20(2), 273-284. https://doi.org/10.4025/psicolestud.v20i2.25547
» https://doi.org/10.4025/psicolestud.v20i2.25547 - Pinho, O. (2019). O corpo do homem negro e a guerra dos sexos no Brasil. In H. Restier, & R. M. Souza(Org.), Diálogos contemporâneos sobre homens negros e masculinidades (1a ed., p. 105-130). São Paulo, SP: Ciclo Contínuo Editorial.
- Pinho, O. (2004). Qual é a identidade do homem negro? Revista Democracia Viva, (22), 64-69.
-
Piza, E., & Rosemberg, F. (1999). Cor nos censos brasileiros.Revista USP, (40), 122-137. https://doi.org/10.11606/issn.2316-9036.v0i40p122-137
» https://doi.org/10.11606/issn.2316-9036.v0i40p122-137 - Santos, P. L. (2006). Problemas de saúde mental de crianças e adolescentes atendidos em um serviço público de psicologia infantil. Psicologia em Estudo, 11(2), 315-321.
- Schucman, L. V. (2018). Famílias inter-raciais: tensões entre cor e amor Salvador, BA: EDUFBA.
- Silva, M. L. (2017). Racismo no Brasil: questões para psicanalistas brasileiros. In N. M. Kon, M. L. Silva, & C. C. Abud (Orgs.), O racismo e o negro no Brasil: questões para a psicanálise (1a ed., p. 71-89). São Paulo, SP: Perspectiva.
-
Silva, N. G., Barros, S., Azevedo, F. C., Batista, L. E., & Policarpo, V. C. (2017). O quesito raça/cor nos estudos de caracterização de usuários de centro de atenção psicossocial.Saúde e Sociedade , 26(1), 100-114. https://doi.org/10.1590/s0104-12902017164968
» https://doi.org/10.1590/s0104-12902017164968 -
Taño, B. L., & Matsukura, T. S. (2015). Saúde mental infantojuvenil e desafios do campo: reflexões a partir do percurso histórico. Cadernos Brasileiros de Terapia Ocupacional, 23(2), 439-447. https://doi.org/10.4322/0104-4931.ctoAR0479
» https://doi.org/10.4322/0104-4931.ctoAR0479 - Zanello, V. (2018). Saúde mental, gênero e dispositivos: cultura e processos de subjetivação Curitiba, PR: Appris.
