Twenty-one interviews were conducted between March and June 2018 in five different schools and two universities. The participants were between 29 and 63 years old and had between three and 38 years of experience in the school environment. Sixteeen were women and five were men. Fourteen interviewees hold a teaching position in their institution, two are pedagogical coordinators, one participant is headmistress, one is an inclusion pedagogue, and four are university psychologists. School 1 is a private school in an upper-class residential area in the city of Sao Paulo; the monthly enrolment fee is about 7,000 reais/month for a child in middle and high school, more than seven times the monthly minimum wage in Brazil (Salário Minimo, Portal Brasil). Schools 2, 3 and 4 are municipal schools in the cities of São Paulo, Campinas, and Joaquim Mourato respectively. They serve a population living in unstable housing or in occupation areas ("favelas"). School 5 is an alternative pedagogy school in the city of Campinas. Universities 1 and 2 are public universities in Sao Paulo State.
The increasing medicalization of student behaviour: from certificates to the prescription of psychotropic drugs
Over the past five to six years, school professionals in our sample noticed a massive increase in the number of medical certificates received, naming a student’s diagnosis or special needs to be considered for their educational plans:
"In the last six years it has increased exponentially. I have been working for a long time, so have my colleagues, and today there is a torrent of diagnoses." (mathematics teacher, 45 years old)
Participants attributed the increase in medical certificates not just to medical reasons alone, but to a desire to respond to “disturbing” child behavior, as perceived by parents and the school. According to participants, naming the behavior by providing a formal diagnosis could temporarily alleviate concern about the behavior:
"We see many families who are sometimes relieved... My son has a diagnosis, [and] it seems that everything was resolved." (school principal, 60 years old)
Despite the comfort to families in providing a diagnosis, participants wondered if the condensing of student experiences into similar diagnoses represents a homogenization that could make students lose their singularity.
“The students’ troubles could come from different things, a family problem, a relashionship issue, a personal question (…) But the shool had a uniform pre-traced way of dealing with these problems, because their goal is to make them calm down” (geography teacher, 48 years old)
Participants noted that the search for the reason behind a student's academic difficulties most often originates from parents, who are the first to ask for explanations. Some participants mentioned parents’ concerns that increased screen exposure may have played a role in the increase in these disorders. Specifically, participants worried that exposure to technology and social networks is reducing students’ attention span:
"The digital tools make them lose focus, because they are looking at you but thinking about what's on Instagram." (biology teacher, 60 years old)
Some participants noted that the increase in medical certificates is less likely due to increasing incidence of the disorders, but rather an improvement in identification through more accurate diagnostic tools and a greater number of trained professionals. Although benefiting from a diagnosis had previously been the prerogative of more privileged circles, better detection of special needs would result in broader access to care for all students:
"Today, making a diagnosis is easier. Twenty years ago, the same student would have been considered uneducated." (mathematics teacher, 45 years old)
Accompanying the increase in medical certificates, participants also noted an increase in the number of students receiving psychiatric medication, such as stimulants, antidepressants, hypnotics, and anxiolytics. According to participants, taking medication is more serious than simply receiving a diagnosis, representing the medicalization of students’ special needs:
"This approach to psychology that puts a label, a diagnosis, that gives drugs is increasing [...] I consider the medicalization in Brazil to be very serious issue." (school principal, 60 years old)
Participants in our sample feared excessive prescription of these psychotropic drugs, viewing medication as an invasive intervention with potential serious consequences. Moreover, their concern about the increased number of students taking psychiatric medications was accompanied by a value judgment, with some considering negligence on the part of parents and carers who do not give this matter sufficient importance in the eyes of the educators, who worried about potential consequences of these medications on students’ development.
The inclusion injunction: an increase in workload felt primarily in the public sector
Because Brazil’s inclusion model requires schools to include special education students in conventional classrooms, school professionals have direct, daily exposure to these students, their disabilities, and their relationships to medical care. For participants, questions emerged about these new students and how to welcome them into the group dynamics of a classroom:
"There are many students who have a disability who are in the classroom; we have to offer them something." (Portuguese teacher)
For many educators, a central issue for the inclusion process was how to adapt the course content for students with disabilities or special needs who are now integrated into the general classroom. Educators’ responsibility to guarantee that students derive maximum benefit from teaching raised another question for participants: How far the school must go in order to adapt to these students’ needs? While some participants believed schools must do everything possible to enable all students to benefit from the schooling available to them, others argued that certain limits must not be exceeded for fear of schooling losing its meaning.
"The role of the school institution is to try to offer as much as possible to reintroduce this person into the school […]. They told me ‘how you can she pass to the next school year if she doesn’t have the sufficient grade? But they don’t take it into consideration that her grade now is already the double of the grade she had before. (…) If a student hasn’t reached the learning required in that school year, but we know he will not have the capacity to reach it even if he does the year again, then how should we proceed? (…) What’s the point of letting him pass on if he hasn’t gotten the required knowledge?” (mathematics teacher, 45 years old)
Participants grappled with the implications of modifications for special education, wondering about the differences in allowing some students to advance based on objective achievement versus modified, relative achievements for students with special needs.
In response to these questions about the educational system’s responsibility toward students with special needs, many participants viewed the obligation to welcome all students in an inclusive model as a rough imposition from the State. They described the burden of increased adaptability on educators’ part to cope with this directive, hampered by the lack of clear guidelines on how to do so:
"It is our greatest challenge, to adapt our courses, our objectives to the students we have, to the profiles of students we have." (Portuguese teacher)
The lack of supportive resources for educators to meet the criteria of inclusive education was a prominent theme for participants. They noted that existing trainings on this new pedagogical demand were insufficient, requiring educators to improvise and perform a function beyond their profession as classroom teachers in order to compensate for the shortcoming of trainings. Participants highlighted that the suffering caused by this burden is not sufficiently taken into consideration:
"There are many teachers who are on medical leave because they are traumatized." (reading teacher, 31 years old)
The lack of resources, while denounced in both public and private networks alike, is more acutely felt in the public-school system. Participants expressed regret that the transition to an inclusion model was executed with more concern for the speed of implementation than for the quality of the intervention, remarking that they are the ones bearing the cost of this lack of preparation:
"We say that the school responds to this diversity, but we do not create the needed structure to do so. We put the bomb into the hands of the teachers and ask them to manage the situation." (geography teacher, 48 years)
Participants’ discontent with the implementation of the inclusion model also takes issue with a perceived paradox in the inclusion injunction: While inclusion is intended to allow students with special needs to receive education as similar as possible to students in general education, the education of each student with special needs is specifically adapted to the the child’s individual needs, and therefore the “general” education is actually created on a case-by-case basis. Participants grappled with the concept of modifications, wondering how each student’s special needs can be considered without becoming a privilege that relieves the student of the educational obligations expected of others. Some went as far as to wonder whether taking a student’s disability into consideration when deciding consequences in fact goes against the principle of inclusion by treating the student differently from students in general education:
“If because of a disability a child can skip a class, the correct compensation would be for the child to receive the teaching in another moment or in another form. But what happens if the child cannot receive this teaching? Can we accept that this child will simply not receive the education that is rightfully his?" (sports teacher, 46 years old)
Faced with this paradoxical request, participants found themselves having to rethink their practices in order to respect their students' right to education while also considering their differentiated needs.
Articulating care and education in schools: defining the specificities according to the socio-economic background
In the face of increasing interface between students’ medical care and schooling, participants desired an effective coordination between these two sectors. Participants questioned how to create collaboration with healthcare providers while preserving the prerogatives of the teaching profession:
"We don't want to take the doctor's place in relation to whether or not to give a drug. On the other hand, we don't want the doctor to tell us how to intervene in the school." (inclusion educator, 35 years old)
As part of the separation between the professions, participants’ desire for collaboration emphasized ownership of each profession’s individual function:
"I think the collaboration is beneficial as long as we don't throw our problems on them to avoid our share of responsibility." (reading teacher, 31 years old)
One example raised of separate but collaborative healthcare within education was school psychologists, which are not yet present in public schools. Teachers expressed feeling helpless with regards to students’ healthcare and desired greater proximity with specialized professionals, in particular psychologists, who would be welcomed in school facilities on a daily basis:
“The ideal would be to have a psychologist in the school directly, because the demand is massive." (pedagogical coordinator, 29 years old)
Despite some participants’ desire for staff like school psychologists, we identified reservations about this new possibility. One participant noted that the benefit of school psychologists would “depend… on how it was set up" (5, history teacher, 33 years). Others feared that additional staff would only serve as a political strategy to hide the structural problems that exist within the school institution, suggesting that the presence of psychologists would only serve to cover up gaps without really addressing them:
“Now we have school psychologists in some schools, to help manage the situation, but I think the problem is more at the base of the school institution." (history teacher, 63 years old)
In addition to this potential change in the structure of the education-healthcare partnership, participants noted that the teaching profession is already changing, and not necessarily in positive ways. Time spent in non-teaching activities is increasing, given the emphasis on a more holistic view of the student, with profound changes in school structure are perceived as inevitable in order to meet this new pedagogical inclusion demand:
"I think that school institution as we know is doomed to disappear. The school must change. " (history teacher, 63 years old)
Participants elaborated on emerging new professional expectations, such as one participant, who serves as an inclusion educator and is responsible for all special education students in their establishment. As the first person to hold this position in their school, the participant noted a difficult learning curve:
“Three years ago, everything was very different. For the school staff to see me as working, I had to be sitting in the classroom next to the student offering something. I had to progressively deconstruct this idea they had of what my work was.” (inclusion teacher, 35 years old)
Other participants described being asked to take on the role of directing students towards proper mental healthcare. As one participant stated, educators use academic performance as “the thermometer that shows the family or school that they need to look at this student, a look with more attention" (21, geography teacher, 35 years old). Based on students’ performance, teachers and coordinators are tasked with identifying which students might require specialized medical care, then performing assessments that go beyond the scope of their traditional practice:
"We put everything we have observed on a form and then we send it, if the student has private insurance, to private insurance. If the student depends on the public system, it is already much more complicated." (pedagogical coordinator, 29 years old)
This comment also reflects the differences in care that are accessible to different students according to social background.
With these new healthcare-related demands on classroom educators, and despite the possibility of school psychologists, another question emerges: While teachers transmit theoretical knowledge and psychologists provide psychological understanding, who is actually responsible for taking care of the students more broadly?
Once again, the situation varies according to social class. In the public system, the obligation to welcome students without discrimination requires confrontation of students’ social realities and inequalities. Faced with the inequities between student populations, participants reported that teachers frequently act as care workers in order to meet the demand of the inclusion injunction. Therefore, schools end up fulfilling a function of hospitality and become an actor in social services, supporting students both financially and otherwise:
"It is not uncommon for schools’ professionals to mobilize and give money to help these adolescents feed themselves, when they don’t have other means." (pedagogical coordinator, 45 years old)
"Both of J’s parents were alcoholics and couldn't take care of him. I protected him a lot at school [… and] the principal asked me,'Do you take responsibility for him?' And I said of course." (history teacher, 33 years old)
In the private system, a very different mechanism guides the school system’s response to inclusion. Given the massive amount of money invested by parents in their children’s education, parents identify as consumers and therefore hold certain expectations of the services provided. To justify the amount paid by parents, these schools offer a personalized approach to each student in order to best meet their individual needs. As one participant stated:
"Our school strives to meet each student’s individual needs. (...) We will offer a differentiated course, a differentiated assessment." (geography teacher, 35 years old)
This private model seems to meet the ideal of inclusion education, but it is not accessible to all students. Although outright discrimination against people with disabilities or illnesses is prohibited, access to private schooling remains selective because of the cost.
In summary, participants have illustrated an increase in the daily confrontation between the education and care sectors, noting an ongoing evolution in the boundaries of their professional skills. This evolution differs according to the social background of the student populations: Whereas the public schooling system serves a lower socioeconomic group of students and consequently adapts by developing care-worker responsibilities, the private schooling system is able to develop a flexible model that is increasingly adapted to each student.
-INSERT Table 1 HERE-
Table 1
Overarching domains from the qualitative analysis
| Themes | Subthemes | Verbatims |
| Increased medicalization of student’s behaviors | Increase in diagnosis | "In the last six years it has increased exponentially. I have been working for a long time, so have my colleagues, and today there is a torrent of diagnoses." (mathematics teacher, 45 years old) |
| Better means to identify disorders | "Today, making a diagnosis is easier. Twenty years ago, the same student would have been considered uneducated." (mathematics teacher, 45 years old) |
| Increase in medicalization is preoccupying | "This approach to psychology that puts a label, a diagnosis, that gives drugs is increasing [...] I consider the medicalization in Brazil to be very serious issue." (school principal, 60 years old) |
| The inclusion injunction | Inclusion requires adaptations | "There are many students who have a disability who are in the classroom; we have to offer them something." (Portuguese teacher) |
| | Lack of sufficient guidelines and resources | "We say that the school responds to this diversity, but we do not create the needed structure to do so. We put the bomb into the hands of the teachers and ask them to manage the situation." (geography teacher, 48 years) |
| | The inclusion paradox | “If because of a disability a child can skip a class, the correct compensation would be for the child to receive the teaching in another moment or in another form. But what happens if the child cannot receive this teaching? Can we accept that this child will simply not receive the education that is rightfully his?" (sports teacher, 46 years old) |
| Articulating care and education in schools | Collaboration between school and healthcare professionals | "I think the collaboration is beneficial as long as we don't throw our problems on them to avoid our share of responsibility." (reading teacher, 31 years old) |
| Care expected from school professionals | "Both of J’s parents were alcoholics and couldn't take care of him. I protected him a lot at school [… and] the principal asked me 'Do you take responsibility for him?' And I said of course." (history teacher, 33 years old) |
| Uprising of new professions | “Now we have school psychologists in some schools, to help manage the situation, but I think the problem is more at the base of the school institution." (history teacher, 63 years old) |