CHILDHOOD MEDICALIZATION, SCHOOL FAILURE AND THE GUARDIAN COUNCIL: A HISTORICAL-CULTURAL ANALYSISABSTRACT
The present article approach the context of the medicalization of childhood in light of Cultural-Historical Psychology and as a method of analysis the Dialectic Historical Materialism. The objective of the research was to explore the complaints of a medical nature from schools that are referred to Conselho Tutelar and what plan of action is in this institution. The outlining of the research was qualitative in character and data was obtained through semi-structured interviews carried out with officials of three Conselhos Tutelares located in the west of Paraná. We observed that Conselho Tutelar is used as a school support instrument to board students who exhibit behavior perceived as inappropriate, the school, instead of looking for professionals of their own education, forwards them to a rights guarantee body. We perceived that the reasoning present in this organization comes from bourgeois medicine with totally biological support which results in the blaming of children, teenagers and their families members due to the failures of the school. We conclude that the solution found by the officials is to refer these children and teenagers to the medical specialist in order to medicalize the student, without questioning the biologizing medical logic, waiting for an immediate result.
Keywords:
Cultural-historical psychology; medicalization; conselho tutelar
RESUMO
O presente artigo aborda o contexto da medicalização da infância à luz da psicologia histórico-cultural e como método de análise o materialismo histórico dialético. O objetivo da pesquisa foi explorar as queixas escolares de cunho medicalizante que são encaminhadas ao Conselho Tutelar e qual a lógica de atuação deste órgão. O delineamento da pesquisa foi de caráter qualitativo e os dados foram obtidos por meio de entrevistas semiestruturadas realizadas com os representantes de três conselhos tutelares de uma comarca localizada no oeste do Paraná. Observamos que o Conselho Tutelar é utilizado como um instrumento de apoio da escola para abordar os alunos que apresentam comportamentos compreendidos enquanto inadequados, a escola ao invés de procurar profissionais da própria educação encaminha a um órgão de garantia de direitos. Percebemos que o raciocínio presente neste órgão advém da medicina burguesa com respaldo totalmente biológico o que resulta na culpabilização das crianças, adolescentes e seus familiares pelo fracasso escolar. Concluímos que a solução encontrada pelos conselheiros é encaminhar essas crianças e adolescentes à especialidade médica a fim de medicalizar o aluno, sem questionar a lógica médica biologizante, esperando por um resultado imediato.
Palavras-chave:
Psicologia histórico-cultural; medicalização; conselho tutelar
RESUMEN
El presente artículo es acerca del contexto de la medicalización de la infancia a la luz de la Psicología Histórico-Cultural y como método de análisis el Materialismo Histórico Dialéctico. El objetivo de la encuesta fue explorar las quejas escolares de cuño medicalizante que son encaminadas al Conselho Tutelar y cuál es la lógica de actuación de este órgano. El delineamiento de la encuesta fue de carácter cualitativo y los datos fueron obtenidos por medio de entrevistas semi estructuradas realizadas con los representantes de tres conselhos tutelares de una comarca ubicada en el oeste del Paraná. Observamos que el Conselho Tutelar es utilizado como un instrumento de apoyo de la escuela para abordar los alumnos que presentan comportamientos comprendidos mientras incorrectos, la escuela en vez de buscar profesionales de la propia educación encamina a un órgano de garantía de derechos. Percibimos que el razonamiento presente en este órgano proviene de la medicina burguesa con respaldo totalmente biológico lo que resulta en una culpabilidad de los niños, adolescentes y sus familiares por el fracaso escolar. Hemos concluído que la solución encontrada por los consejeros es encaminar estos niños y adolescentes a la especialidad médica a fin de medicalizar el alumno, sin cuestionar la lógica médica biologizante, esperando por un resultado inmediato.
Palabras clave:
Psicología histórico-cultural; medicalización; conselho tutelar
Introduction
Studies have shown that childhood medicalization in Brazil is increasing. According to research conducted by Barroco, Facci, and Moraes (2017), Brazil is the country that most often uses methylphenidate in children. Still, the studies denounce the close relationship between education and mental health, given that school complaints have been the main motivator for the process of child medicalization.
In this context, several services, especially those in the health sector, have been receiving children whose school development is deficient or whose behaviors are considered inappropriate for medical consultations aimed at a diagnosis. The intention is to solve the child's problem based on a model that individualizes behavior without understanding the different reasons for school failure, which includes failures, learning difficulties, and diverse behaviors, among other aspects.
It turns out that other sectors have also been activated to resolve school complaints associated with medicalization, as seen in research undertaken by Bett (2017). The author, when studying school complaints taken to Guardianship Councils, observed that such complaints were often associated with the process of childhood medicalization. It is not uncommon for schools to refer children and adolescents to councils so that mental health care spaces can be made available or even so that parents can be held responsible for failure to comply with school guidelines such as taking the child to the doctor for diagnosis or administer medication, as per medical order, carry out follow-ups in the network, among others (Bett, 2017).
Thus, we see that school complaints and medicalization are associated with the area of Child and Adolescent Law. It is with the aim of better understanding this relationship that we establish the central objective of investigating situations of childhood medicalization that end up being taken to the Guardianship Council and their respective referrals, analyzing this process in the Sistema de Garantia de Direitos - SGD (Rights Guarantee System). Given this, some questions arise: What situations are associated with medicalization, and have guardianship councils received them? Under what justifications? What is the school's relationship with the guardianship council and mental health services? What types of responses to school complaints and the medicalization process have been produced in the children and adolescents' rights field? How does the service (Guardian Council) understand medicalization?
We understand that the answers to these questions enable a better understanding of the medicalization phenomenon and respective coping strategies, as they explain the intersectoral plot that has served to maintain this phenomenon by being anchored in the Rights of Children and Adolescents.
By adopting Historical-Cultural Psychology as a theoretical framework, we seek to break with traditional models that justify the social inequality of the capitalist system through individual responses in a movement that aims to overcome the phenomenal appearance of medicalization, which supposes a significant increase in the number of mental disorders in childhood, but which, on the contrary, only indicates a way of understanding the psyche limited to organic aspects that do not consider the dialectical relationship between subjectivity and objectivity, where the mode of material production, the objective conditions of life such as housing, socioeconomic conditions and political relations, outline the possibilities of human development. In this sense, we understand that demonstrating the different forms of expression of the medicalizing process, as well as the mechanisms that support it, as is the case of the transfer of educational conflicts to the Guardianship Council, consists of a task in line with the ethical-political commitment of Psychology. Such mechanisms are based on liberal ideology through processes of exclusion based on the principles of individuality, freedom and equality, points that denote a social problem, and the attribution of a biological justification to an issue that covers the social field.
The childhood medicalization process: current panorama and its support bases
For contextualization purposes, it is necessary to realize a historical review of the theoretical-methodological bases that support the current process of medicalization. We understand that historicity allows the overcoming of dichotomous views that marked science in the 19th century, as is the case of positivism, rationalism and mechanism, carrying the possibility of criticism and overcoming an abstract view of the psychological phenomenon. To this end, we will address the concept of medicalization, pointing out some aspects of its current panorama in Brazil in childhood, as well as seeking to bring to light the theories that have historically been consolidating life biologizing models in a process of individualization of social phenomena, anchored in liberal ideology.
The concept of medicalization, for Barroco et al. (2017), refers to a process in which problems of a historical and social nature end up being understood as strictly biological and thus commonly described in the form of disorders and diseases. According to the social movement "Forum on Medicalization of Education and Society", the concept of medicalization speaks of a deterministic rationality that disregards the entire historical and cultural construction of human life, reducing it to its organic aspect (Brasil, 2018). Therefore, it is the individualization of phenomena that have historical and social bases reduced to biomedical explanations.
The man biologization and individualization reduce the subject to medical prescriptions in a movement to trivialize the use of medicines. As explained by Barroco et al. (2017), data from Anvisa - Agência Nacional de Vigilância Sanitária (National Health Surveillance Agency) point to the high consumption of methylphenidate, better known as Ritalin, by children and adolescents aged between six and sixteen years in the period from 2009 to 2011, revealing absurd numbers of the total of boxes sold in a short period (three years) for this age group, and showing an increase of 75% in the sale of the medicine. In general contexts, according to the Sistema Nacional de Gerenciamento de Produtos Controlados -SNGPC (Controlled Products Management of National System), the sale of methylphenidate increased by 28.2% in Brazilian pharmacies and drugstores, which makes Brazil the second largest seller of this drug, second only to the United States (Suzuki, 2017).
The increasing use of children's medication is closely related to school complaints. The focus of the use of methylphenidate is on school-age children. This fact happens because the difficulties that arise in the schooling process are categorized from an organic perspective and justified by the actions of medicine. The high number of students who use medication to solve learning and behavioral impasses is notable, as schools increasingly seek to clarify problems that arise from other factors due to the socially accepted medical-biological model, which is a quick and effective solution. (Suzuki, Leonardo & Leal, 2017).
According to Suzuki et al. (2017), it is through moralizing speech that this process is introduced into education. The speech of most teachers interviewed by the author, as mentioned in the research above, concerns student behavior classified as rebellious, which would make their learning process difficult. Rossato, Constantino & Leonardo (2017) ensure that medicine then turns its attention to school and behavioral problems, concluding that they are neurological disorders, which results in guidance for parents to take their children to health professionals to be medicated. With this, the school seeks answers in medicine to deal with the most complex pedagogical issues and simultaneously becomes an establishment to realize hygienist methods, not only with the student but also with the family (Martins, 2011).
This logic that legitimizes the pathologization of the behaviors presented by the child has as its epistemological basis the practices of classical bourgeois medicine that, in Brazil, is consolidated through the hygienist movement at the end of the 19th century. During this period, various civil and state institutions were established, such as medical associations, enunciating several health proposals, such as the Liga Brasileira de Higiene Mental - LBHM (Brazilian League of Mental Hygiene), from 1923, which was part of the hygienist movement (Moura, 2012). LBHM was concerned with centralizing and alleviating the social ills present in the country, arising from urbanization, and in the 20th century, through the pro-mental hygiene movement, LBHM's social medicine was introduced into the intimacy of families (Boarini, 2012; Moura, 2012).
According to Martins (2011), hygienism sought, through education, to reduce pedagogical problems, such as school dropout, failure and absences due to class attendance, to then reach a utopian healthy homeland. Mental hygiene proclaimed that it was necessary to go beyond the school walls, introducing itself into the child's contexts, mainly the family, with the aim of encouraging healthy habits from the ages that precede the school period.
With the consolidation of cleaning practices, social and cultural problems such as unemployment, poverty, lack of decent housing, and lack of food, among others of a pedagogical nature, were not analyzed carefully but rather individualized without reflecting on the material conditions of the subjects' existence. Within capitalist logic, this individualizing vision in the context of education seeks to produce healthy adults permeated by positivist political ideologies and legitimize and justify school failure without questioning the educational system itself (Martins, 2011).
In Brazil, hygienist doctors had assiduous participation in the proliferation of psychological knowledge, which justifies the importance of recognizing the proximity of this hygienist political character of society to the role of psychological science (Faggion, 2018). Psychology in the 1980s was based on biologizing models of bourgeois medical clinics, contributing to this process of subject individualization being authorized, which, nowadays, legitimizes the immediate perspective to solve issues, as is the case with the use of medication in children's problems (Beltrame & Boarini, 2013).
Then, medication has become a solution to problems of all kinds. The referrals produced from this perspective based on school complaints, as well as passive acceptance by family members or those responsible for the child/adolescents, demonstrate the population's lack of knowledge about the learning processes. Medicalization presents itself as an expression of social Darwinism that psychology has helped to sustain for many years (Beltrame & Boarini, 2013).
According to Patto (1999), this individualization becomes more significant because of the liberal ideology that reduces school failure to the student and the teacher. From a liberal perspective, all men are free and equal, so their differences are explained by individual characteristics/abilities.
It is important to highlight the role of psychology, which contributed to the process of individualization in school failure. Psychology in force at the end of the 19th century was committed to quantifying the human mind, with its main task being to measure intelligence, thus creating the categorization of subjects, supported by the implementation of the use of psychological testing, as well as authorizing exclusion processes with students who had learning difficulties (Patto, 1990). So, the connection between medicine, school and psychology emerges with the hygienist model adopted as a basis, which, for Beltrame & Boarini (2013, p. 342), authorizes and gives space to care that is often reduced to just the use of medications, understanding these as a "magic formula" for solving problems presented by children in the school context.
Despite being a recent phenomenon, we note that medicalization has its roots more than 100 years ago. This movement goes beyond the context of medical science. Several professionals from other areas adopt this logic to conduct assessments and diagnoses. As a treatment proposal, they only enable the use of medication without allowing different ways of facing what has been characterized as a disease (Suzuki, 2017).
Human development in Historical-Cultural Psychology and the opposition to the Biomedical model and Naturalizing psychologies.
In the conception of Historical-Cultural Psychology, there is a dialectical relationship between objectivity and subjectivity, as well as between individuals and society. This conception is opposed to traditional psychological theories with a positivist basis, whose method of understanding reality is based on natural sciences. Dialectical Historical Materialism, the basis of Historical-Cultural Psychology, sees man as a social and historical being, a product and producer of his existence, considering the material reality in which he is inserted. The dialectical relationship between man and objectivity underlies the studies of psychological phenomena by Historical-Cultural Psychology since man is understood as the result of a social formation process of everyone, in which subjectivity is established through social mediations, that is, the intersubjective plane of relationships is transformed into an intra-subjective plane, in the development process (Tuleski, 2008).
It was through work that man developed. According to Leontiev (2004), from the moment society is organized based on work, socio-historical laws also govern the individual. The author also states that man only meets the world in which he is inserted through relationships with other men, mainly via language. Therefore, typically, human characteristics are transmitted via a mediated relationship, as well as through cultural objects created by men themselves, and with this, culture is incorporated. This incorporation allows the development of abstract thinking and, from this, higher mental functions. For this abstraction process to happen, it is necessary to conceive a relationship among objects, historical phenomena and an activity that portrays what has already been incorporated into that object (Leontiev, 2004).
When Vygotsky (1931) researched the development of higher mental functions, he concluded that man has Elementary Mental Functions - EMFs (reactions, movements, etc.) and Higher Mental Functions - HMFs (voluntary attention, verbal thought, logical memory, etc.). EMFs are biological specificities of the psyche and vary according to environmental stimuli. HMFs are social functions and react based on stimuli created by man himself. That is, every EMF goes through an external development process since it is Social.
In this way, contact with the material world intentionally provides the basis for the emergence of human roots, as well as serving as a driving force in expanding the psychic development of this primitive man (Vygotsky, 1931). According to Vygotsky (2007), the acquisition of this cultural framework by the child occurs now when he begins to signify objects through the senses. The child, through contact with the signs, incorporates them, making his thoughts organized, helping him in the process of meaning and intentional use of tools endowed with culture. This behavior is typically human behavior, which differs from the actions adopted by animals, considering that they are unable to appropriate the cultural legacy materialized in the created instruments based on human needs throughout history.
The most decisive part of child development is when the child begins to use the tools created historically and culturally, even in the earliest stages of development (Vygotsky, 1931). To expand the child's psychic development, as well as mediation with cultural objects created throughout history, the learning process becomes necessary. Thus, access to education is essential for man to understand history. People do not become human from themselves, but from "[...] objectified and enabled humanity to their internalizations [...]" (Martins, 2011 p. 213).
The child's learning process begins even before entering school, with the knowledge already acquired from everyday life, and does not occur linearly or regularly. When children enter school, they are faced with new external stimuli, but they also increase what they have previously incorporated. Therefore, the HMF development only occurs to the extent that external cultural means such as writing and language are mastered, thus developing abstract thought by forming concepts (Vygotsky, 1931).
School education is linked to a process that aims to provide the appropriation of knowledge that has already been systematized throughout history, which seeks to broaden the students' field of meaning. As such, it is important to use a certain degree of complexity in the practices and quality of the mediation accessible in the school environment so that they provide a certain basis for children's development, enabling it to overcome itself dialectically (Martins, 2011). In this way, it is understood that learning is anchored in the dialectical process of human development and, therefore, to overcome the medicalizing response linked to learning, it is necessary to adopt a referential basis that understands learning beyond liberal ideas.
Nevertheless, based on the struggle of opposites as a necessity to generate movement in society, Historical-Cultural Psychology, opposing liberal models, presupposes historicity as the foundation for man's development and demarcates human development in a dialectical way, that is, presenting man as a synthesis of the relationships established in society. Thus, the development of higher mental functions is anchored in the material base (Facci, Leonardo, & Ribeiro, 2014).
Legislation and childcare
Regarding the historical context of learning as a right guaranteed to children and adolescents, it was only after the 17th century that the notion of teaching as a right for all and a duty of the State emerged. In Brazil, it was only with the Federal Constitution of 1988 that education, in fact, became a right for all, free and guaranteed by the State and in 1990, with the promulgation of the Estatuto da Criança e do Adolescente - ECA (Child and Adolescent Statute) (Federal Law 8.069 /90), this right, as well as other children and adolescents fundamental rights, are ratified and are now monitored by a body created by the same law, namely, the Conselho Tutelar (Guardianship Council).
The ECA in its art. 4th guarantees that it is the duty of the family, the community, society in general and the public authorities to ensure, with absolute priority, the implementation of rights relating to life, health, food, education, sport, leisure, professionalization, culture, dignity, respect, freedom and family and community coexistence. Sole paragraph. The guarantee of priority comprises a) primacy in receiving protection and assistance in all circumstances; b) precedence for assistance in public or relevant services; c) preference in the formulation and execution of public social policies; d) privileged allocation of public resources in areas related to children and youth protection (Federal Law n. 8.069, 1990).
Education, in the ECA, is directed by 06 articles (53 to 59). In art. 53 the ECA establishes that children and adolescents must have the right to education, aiming at the full development of their person, preparation for the exercise of citizenship and qualification for work. (Federal Law No. 8.069, 1990). We note in art. 98 of the ECA that protection measures for children and adolescents are applicable whenever the rights recognized in this Law are threatened or violated: I - by action or omission of society or the State; II - due to lack, omission or abuse of parents or guardian; III - due to their conduct (Federal Law no. 8.069, 1990). The Lei de Diretrizes e Bases da Educação Nacional - LDB (Law of Guidelines and Bases of National Education), in its art. 4th guarantees that education is the duty of the State and in art.5th guarantees that access to compulsory basic education is a subjective public right and that any citizen, group of citizens, community association, trade union organization, class entity or other legally constituted entity, as well as the Public Prosecutor's Office, may sue the government to demand it (Law 9.394, 1996).
In this light, art. 101 of the ECA guarantees that any of the hypotheses provided for in art. 98, the competent authority may determine, among others, the following measures: I - referral to parents or guardian through a term of responsibility; II - temporary guidance, support and monitoring; III - mandatory enrollment and attendance at an official primary education establishment; IV - inclusion in official or community services and programs for the protection, support and promotion of families, children and adolescents; (As amended by Law No. 13.257, of 2016) V - request for medical, psychological or psychiatric treatment, on a hospital or outpatient basis; VI - inclusion in an official or community program of assistance for guidance and treatment for alcoholics and drug addicts; VII - host institutions (Wording given by Law No. 12.010, of 2009), VIII - inclusion in a family care program; (As amended by Law No. 12.010, of 2009) IX - placement with a foster family (Included by Law No. 12.010, of 2009) (Federal Law No. 8.069, 1990).
The Conselho Tutelar - CT (Guardianship Council) is a non-jurisdictional, autonomous, and permanent body whose purpose is to defend children and adolescents' rights and must be activated whenever there is a threat or effective violation of any rights concerning them. The CT's duties (art. 136 of the ECA), among others, are to assist children and adolescents by applying protective measures and, when necessary, request public services in health, social services, education, work, security areas; forward to the Public Prosecutor's Office news of fact that constitutes an administrative or criminal offense against their rights; forward to the judicial authority the cases within its competence (Federal Law No. 8.069, 1990).
Legislation, therefore, brings together different equipment, such as schools and guardianship councils, with a view, at least in theory, to guarantee children and adolescents' rights, as is the case with education and health. We must consider that the school is the one who ends up activating the CT due to the failure expressed by the problem student, and this body seeks to ensure that children and adolescents' rights are enforced. However, we must also consider that school complaints arising from school failure are expressed on the limit between what constitutes the protection of a child and its control through medicine, reproducing the individualization of failure, as will be seen in the following work from the data collected in the research.
Method
To understand the object studied, we sought to conduct an exercise in Dialectical Historical Materialism, which aims to reveal the essence of the phenomenon based on the object's structure and dynamics (Konder, 2000). Dialectical Historical Materialism concerns a way of understanding reality that allows us to perceive the movement of contradictions present in society, going against capitalist ideals that defend an immutable fact. This way of thinking allows man to perceive the possibilities of transforming reality; it is the result of a historical basis that goes against linearity (Konder, 2000).
Psychology, when using the method mentioned above, considers man from his historical and social context, as well as understanding that subjectivity is constituted in objectivity and social phenomena, as is the case of medicalization understood here as an expression of the contradictions of society, as are the Law and the current scientific model, which establishes a universal and the psyche organic understanding.
Based on the above, we sought to explore the varied determinations of reality, which led us to the need to understand, historically, the genesis of the process of medicalization and the construction of legislation and child care in the country, as well as school failure in capitalist classes society, and not just look at clusters of behavioral symptoms and their referrals to different Sistema de Garantia de Direitos da criança e do adolescente - SGD (Child and adolescent rights guarantee system) services.
In methodological terms, three CTs from a district in the western region of Paraná were studied. After authorization of the research by the presidents of each council, it was submitted to the Ethics committee and approved under nº 17794919.0.0000.0109.
The research design was qualitative, through which we sought to understand the existence of referrals from schools to councils, with a view to diagnoses and/or medical and medication treatments, what are the motivations for such referrals (if they refer to school complaints or other motivations), and what measures are taken by counselors in the face of such school situations that arise and the reasons for such measures. As Martins (2006) states, the qualitative aspect of the research aims to understand what cannot be reduced to numbers, such as the motivations for referrals and measures taken by counselors. This aspect is important to understanding totality, which is not restricted to a phenomenal description but also to historical analyses of the object (Martins, 2006).
The quantitative aspect, which would allow us to assess the incidence of medicalization brought to the guardianship councils in the region studied, was not undertaken, as the councils did not provide the means for us to survey the number of situations with the characteristics mentioned above to clarify the objectivity of the phenomenon studied.
The data collection tool was a semi-structured interview with representatives of the respective councils, one from each, with the exception of one of the councils in which two representatives took part because, at the time of the interview, they were both on-site and willing to participate.
Results and Data Analysis
The data collected shows that CT has been used to solve everyday situations related to children and adolescents' health. The most recurrent requests made to the councils associated with health refer to enabling and accelerating access to vacancies in health services, especially referrals to psychiatrists and neurologists.
In general, those who contact the councils with such requests are the schools. Only one of the guardianship councils is not contacted directly by schools for referrals to medical specialists. However, the counselor interviewed reported that families seek guidance from schools. In this sense, the objective is the same: to enable and accelerate medical care. Box 1 presents this demand in each council.
Throughout the interviews, we realized that the CT presents itself as another tool in the medicalizing process, as counselors understand in an individualized way the complaints that are offered and, in the same way, they know the search for medicine and drugs as a form of protection and guarantee of the rights of children and adolescents. In CT3, the medicalization process is presented as follows: the school guides the family, and based on this guidance, they seek out the CT to obtain a vacancy in a specialist.
The counselors, in turn, contact the health department staff so that consultations with specialists (neurologist and psychiatrist) are made available, since according to the counselor, "[...] it is this child's right, as a child has absolute priority and it is a constitutional provision, so... we are triggered, but only when the family is unable to do so, right? [...]".
When contacted either by the school or by families, counselors seek to resolve situations in a variety of ways. The CT1 counselor stated that these referrals are processed by official letters and certify that "[...] the school asks us to speed it up, take the family and so on, speed it up to be a little faster [...]". With this, we observe that the guardianship council has been used as another device in the consolidation of the growing medicalization of childhood.
On the other hand, at times, there was criticism of the excessive use of medication by school-age children. For example, the CT2 counselors, when asked about their understanding of school complaints and the use of psychotropic drugs, express that, [...]in fact, considering the complaints from schools, I believe that most children would be medicated, due to bad behavior or something like that, it's... " imperativeness " [...] as well as bringing a perspective on how the child or teenager should behave in the classroom so that teachers have reasons to request follow-up in a medical specialty, as well as medication for this population. Let us take a look at the following excerpt: [...] he only harms the progress of the lessons in the classroom; he doesn't sit still; there's no learning and so on, so they think it's necessary to refer him, to take medication, to centralize him... it's not every case that needs it, right? [...].
We observed, however, that the process of medicalization is rarely questioned, except for one statement or another that sometimes criticizes the medication that leaves the child "doped" (CT1). At the same time, they bring up in their speech that "[...] he's much better [...]" (CT1); "[...] improved 90% everywhere he went[...]" (CT1); "[...]no more complaints. [...]" (CT1); "[...]you know... in the vast majority, almost 100% of the reports we hear from families, is that when children use medication, they really start to improve[...]" (CT3). Even with negative criticism regarding the use of medicines, the prevalent meaning in the interviews was that of medicalization as a form of protection.
This movement reveals the contradictions between the understanding of the harm of medicine and its supposed benefits. In this sense, we pay attention to what Suzuki et al. (2017) point out: biological medical logic is not dissociated from everyday life. It serves as a background in the work of various professionals. The sometimes-opposing meanings presented in the counselors' speeches are an expression of the contradictory movements of society itself. There is a fine line between the notion of protection through the guarantee of rights and social control of behavior. When there is no access to healthcare, guardianship advice is sought, as specialized medical care is a children and adolescents' right. In this sense, we understand that, in fact, the council has assumed an important role in making services viable. On the other hand, we noticed that there is a submission to the clinical and medicinal vision.
It is important to consider that most counselors do not have higher education, and even if they did, not all training would allow them to make such an assessment. Agreeing with Silva and Leonardo (2012), we understand that "it is not about blaming the professional individually. On the contrary, our society does not value scientific knowledge and professional training based on deeper philosophical foundations [...]" (p. 79).
About referrals to specialties, in CT2, counselors request psychological care and end up referring children/adolescents to neurologist consultations because, according to counselors, parents do not seek care if this supervisory body does not issue the request. This aspect is related to a concept about family that has been recurring in the SGD, which is that of family neglect. According to research by Bett (2017), there are a significant number of school complaints that are presented to guardianship councils and explanations for such complaints have been sought from the family, which ends up being labeled as negligent, especially if they do not adhere to the requested treatments and interventions by schools and other system service professionals.
In this sense, the counselors also explained that the cases that go to the CT are recurring cases of negligent conduct on the part of family members when they do not correctly administer the medication to children and young people or when they do not take the child to appointments. What most impacts the reports of the CT2 guardianship counselors when dealing with some families is that "[...] they end up not seeking care if we don't request it. So, we have already given them this guidance: look for it, and then it will come! They go to the doctor, and the doctor gives the referral... then they always go to the neurologist! [...]".
This report leads us to reflect on the family's impossibility of denying what is determined by public policy professionals, given the tacit acceptance that medical/drug treatments, especially neurological, are the solution to childhood problems and that taking such procedures is a form of protection. The family, in this context, is obliged to follow instructions under the possibility of being held responsible for omission/negligence. There is, therefore, no space for the family to question what is determined for them, a movement that, according to Nascimento (2016), would be a form of protection for the family itself. Furthermore, the interviewee from CT1 reported that most families referred to CT belong to a social class characterized by poverty.
In view of this, we return to the historical-cultural perspective of subjectivity, which is constituted by objectivity. Leontiev (1978) assures that in the current social organization, development does not happen equally to everyone since how man appropriates historical and cultural productions is not made available, just as he does not have access to the material that he produced. In this sense, we must consider different aspects as producers of school failure, especially the precariousness of Brazilian public schools marked by poor training of professionals, poor remuneration, inadequate recognition of teachers, contradictions in the educational programs of the Ministry of Education, lack of material and human resources, among many other aspects that must be considered before attributing school failure to organic aspects. Given this, we wonder whether the negligent family movement would not, on the contrary, be about controlling poor, historically marginalized children, inverting the logic of what is apparently presented as protection (Bett, 2017).
This expression within the family, according to Facci, Silva and Ribeiro (2012, p. 166), is justified [...] for the maintenance and reproduction of the bourgeois social order, the medical order interfered in the family, to guide and monitor both the space of the house and the bodies - of children and adults. So, in accordance with what was explained, let us see how this is expressed in each CT according to the Box 2.
We realize that regardless of how relationships between CTs and families are established, there is a childhood medicalization expression. The role of the CT is only to facilitate access to medicine, consultations in specialties and enabling travel to the place where drug distribution is done.
We must consider what Meira (2012, p. 98, our emphasis) brings us, "every day, students are diagnosed as difficult, unbalanced, depressive, manic, bipolar, aggressive, introverted, and many begin to join the waiting list for care in public health services across the country". Therefore, regardless of the situation, the solution is a referral to a specialty, in this case, neurological, so that the child's problem can be found in his biological apparatus.
Nevertheless, from a historical-cultural perspective, "[...] the development of man's behavior is always primarily conditioned development not by the laws of biological evolution, but by the laws of the society historical development (Vygotsky; Luria, 1996, p. 91), that is, it is not enough for us to explain man only through his biological apparatus. We understand, then, that man is already born into a society with historicity materialized in cultural objects transmitted by previous generations. Yet, it is not a ready-made society but one in motion. Therefore, a child who is inserted into a society that reproduces academic failure has limitations and vague tools for the development of his superior psychological functions.
Another aspect investigated was the case study, which is a working tool for guardianship counselors. As such, it could enable a broader view of school failure on the part of the intersectoral network of services to children and adolescents.
The Figure 1 indicates that in the studied municipalities, discussions among teams from different services with the CT, when they occur, aim at strategies for adherence to medication treatment, again, without any questioning of the medical order, which reinforces the idea that the CT ends up serving as legitimation and medicalization tool.
Final considerations
Despite protecting and guaranteeing children and adolescents' rights, this research demonstrates that guardianship councils have been constituted as yet another tool in the gear system of childhood medicalization. It is, therefore, a powerful instrument since, as a representative of the law, it has the possibility of warning and referring to the juvenile justice system those who do not follow the professional guidelines that, ideologically, will protect the child.
The flow of childhood medicalization to the Guardianship Council is justified by the vision defended by capital, and our objective is to adopt a position that opposes bourgeois society's quest to explain the human psyche only through biological means (Meira, 2012). According to Leontiev (2004), it is understood that socio-historical laws govern man in addition to biological laws. If human existence is explained only from a biological perspective, man's action would be aimed at survival, governed exclusively by instincts. However, this man, through language and relationships with other men, acquires knowledge about the world and himself. Thus, typically human characteristics are transmitted through a mediated relationship when accessing cultural objects (signs) created by men themselves intentionally. With this, there is an incorporation of culture, which allows man to develop higher mental functions (HMF).
Thus, considering the HCP assumptions, we must fight critically against this reality that reinforces school failure anchored in such a biological perspective since a large proportion of children/adolescents are lacking in material bases due to “[... ] the process of hiding the production and reproduction of social inequalities [...]” (Meira, 2012, p. 100) which ends up engendering the exclusion of children and/or adolescents through the medicalization of childhood. The medicalization criticized here is understood as an expression of the social issue in a system that sees subjects as bearers of problems instead of systematizing strategies that aim at humanization, providing conditions and tools that enable the psychic transformation of these subjects.
We also understand the importance of research into the process of childhood medicalization and its flow into different sectors. Moreover, we realize the need for critical professional training for guardianship counselors since they are based on common sense and come from the positivist vision. The capitalist system is also expressed in the school environment, resulting in a lack of criticality, which results in a reproduction of the alienating logic in which the student is seen as solely responsible for their learning. In this respect, another pertinent point is to investigate the training of educational professionals since we understand them to be conscience-formers, and it is of the utmost importance that they can provide the necessary mediation for students in the teaching-learning process, with a view to better developing their higher mental functions.
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Source: Conducted interviews with guardianship counselors.
Source: Conducted interviews with guardianship counselors.
Source: Conducted Interviews with guardianship counselors.