Therapeutic Community for Adolescents : a systematic review of the literature between 2002 and 2013

O presente estudo constitui-se em uma revisão integrativa sistemática de artigos científicos publicados no período entre 2002-2013, objetivando analisar as publicações que relacionam a temática comunidade terapêutica e adolescentes, indexadas em bases de dados previamente determinadas. Os artigos foram organizados e classificados para a análise final realizada a partir de indicadores bibliométricos. Duas temáticas principais foram identificadas, a primeira foi constituída por três artigos que tratam da avaliação e resultados do tratamento. A segunda temática, contando com quatro artigos, discorre sobre aspectos do processo de tratamento. Os estudos apontam para resultados positivos no atendiment o com maior tempo de duração desses adolescentes. Identificou-se a escassa produção científica sobre o tema, especialmente em âmbito nacional.


Introduction
The use, abuse and dependence of psychoactive substances -PAS -has being increasing in the individual and collective scale, impacting the sphere of public health and public safety, on issues related to drug trafficking, violence in different areas, among others.The impacts suffered on such circumstances SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.jan.-mar.2016;12 (1):48-57 of the provision of the services from the 2000s (9) .Adolescents are also cared for in these spaces repeatedly, either voluntarily, by family demand and/or judicial referrals, in line with what is established in the Child and Adolescent Statute (ECA) (10) .
The increase of this service in TCs justifies the study on this type of community so as to provide knowledge and qualifications on this service, considering that it is also being widely used in the country by adolescents with eating disorders from the use and abuse of alcohol and drugs.
In this scenario, our study aims to do a systematic review of scientific articles on therapeutic communities and the attention given to adolescents, in the period between 2002 and 2013.

Materials and Methods
A systematic review uses the available literature to assess publications on a determining subject.The critical analysis and synthesis of the information selected are carried out from the objectives and based on predetermined criteria of exclusion and inclusion (11) .
The databases used in our study were: PubMed (search engine for Medline), Medline (Medical Literature Analysis and Retrieval System Online), IBECS (Indice Bibliográfico Español de Ciencias de la Salud) and Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde).
Search protocols were based on studies on the subject "therapeutic community" in the period 2002-2013, written in English, Portuguese or Spanish.
For the databases Medline, IBECS and Lilacs, we used the DeCS (Health Sciences Descriptors) "Comunidade Terapêutica" (Portuguese), "Comunidad Terapéutica" (Spanish) and "Therapeutic Community" (English).For the PudMed database, for the better specification of the studies found, we decided to use the keywords "Substance Abuse Treatment Centers"[mesh] AND "TherapeuticCommunity" [mesh].
Although the research proposes to study the subject of therapeutic communities and adolescents, in the initial search we did not include the keyword related to adolescent/ adolescence.The choice of the subject of TC and adolescent was carried out after reading and sorting the titles and abstracts of the articles found.
According to the criteria established, we instantly excluded articles that did not fit in the period between 2002 and 2013 and that were not written in English, Portuguese or Spanish, and also those which: a) were literature review studies, b) had no abstracts, c) did are not restricted to the individual, but they extrapolate to the social, family and community space, thus becoming the focus of action of various public and civil society policies.
In Brazil, in recent years, epidemiological studies have shown an increase in the use and dependence on PAS among the population, relating to the expansion of consumption of both illicit and legal drugs.The use among adolescents also shows an alarming growth (1)(2)(3) .The specifics and complications arising from the use of PAS among adolescents are the focus of concerns because of their particularities.Such particularities make it difficult the provision of primary care in the same way as the care that cover the needs of these adolescents.
The country has a network of services for the treatment of this population, with actions from the social assistance policy, judicial power, private services, charities and religious entities and the actions developed by the Brazilian Health System -SUS.The actions performed by SUS, Ordinance No. 3088 of December 23, 2011, "establishes the Network of Psychosocial Care (RAPS) for persons with mental pain or disorder and with needs arising from the use of crack cocaine, alcohol and other drugs."In this way, treatments are organized through Centers for Psychosocial Care (CAPS), which are the main responsible ones for providing the care to this population.The agents of these centers have the ability of referring patients, among other services, to Therapeutic Communities -TC -, which function in coordination with the network (4) .
It is important to mention that the first mention of these Therapeutic Communities (TCs), as institutions, date from approximately the '40s, in England, where military psychiatric hospitals were originally developed.They intended to break with the hospital vision through the democratization of relations, decrease in the hierarchy, assumption of responsibilities and humanization of the care (5) .
The TCs for the care of adolescents date from 1913 with their first record in England and, from 1920, in Europe and the United States, where several institutions started to use this proposal for the care of "rebel" children and adolescents.This service was particularly based on the sharing of responsibilities and imposing of limits, while the issue of affection and bonding were the central mechanism.The greatest challenge was to merge appropriately the two elements (6)(7)(8) .
In Brazil, for the most part, TCs are private and philanthropic institutions, with the expansion Pedron CBW, Buchele F. not exclusively address the subject studied, d) we could not access the text in full, even after contacting the author, e) addressed the subject of therapeutic community but without reference to adolescents.The inclusion criteria used was studies that addressed the subject of therapeutic community, adolescents and abuse of PAS, in a related matter and in the proposed languages and period.
Of the articles classified, we read and analyzed the material according to the methodological approach adopted (12) .The initial result of our search in the databases originated a total of 301 articles.Of these, 294 were excluded, as 128 articles were not related to the subject studied, 18 did not have an abstract, 13 were literature reviews, 11 did not address the subject exclusively, 2 had no access to the full text, 18 were duplicated and 104 did not address the subject "therapeutic community" and "adolescents" in a related manner.We included seven articles, which make our study.
After the classification and organization of the seven selected articles, they were subjected to a careful and exhaustive reading in order to identify their key elements, exposed in a general figure (Figure 1).Aspects of the process of treatment.
Expresses how the relationships among adolescents are built inside the TC, with emphasis on sexuality.

-PubMed
The experience of drugdependent adolescents in a therapeutic community 2010 Sally Nathan, Michael Foster, Mark Ferry.Drug and Alcohol Review, 29, 531-539.

Aspects of the process of
treatment.
The study brings the experience of treatment in TC from the adolescent perspective.Highlights the social relationships in this space.Analyzes the relations between violence suffered, violent behavior and psychiatric disorders after the passage of the adolescent in the TC.
We also used the analysis from bibliometric indicators, considering that they assist in the selection of scientific information and aim to enable the assessment of the quantitative aspects of the scientific production process, verifying the impact of journals and the dissemination of their information, though it is not necessarily an indication of their quality.The bibliometric analysis also enables the knowledge on the size and characterization of the collection of a particular subject (12)(13)(14) .We considered the issues: database, year of publication, country of publication and methodology used.

Presentation of Results
The results of this study will be presented in two types of analysis, initially the bibliometric one and then the central subjects identified.

Analysis of the bibliometric indicators
The period covered by our study is twelve years (2002-2013).The results found for the seven articles over the years presented some gaps, and we selected no article for 2002, 2005, 2006, 2009, 2012, and  2013.In 2004, we selected two published articles, Pedron CBW, Buchele F. and for the other years -2003, 2007, 2008, 2010 and 2011 -an article for each year.Such data indicate that the scientific literature on the subject remained stable, however scarce, and there were no significant changes during this period.
In Table 1, we can see the distribution of the articles according to the databases searched.The highest concentration of articles occurred in the database PubMed.The database Lilacs has only one article and Medline two; Ibecs, on the other hand, although included as one of the databases researched, provided no article for this study.
We highlight the fact that the databases PubMed and Medline concentrated articles in the medical and nursing area, mainly from the USA, indicating that the subject of TC and adolescents appear to be more focused in the discussions in these specific areas and on American soil.At the same time, Lilacs, which covers the Latin America and Caribbean publications, had just one publication, thus demonstrating little scientific production in these regions.Such fact corroborates with the data related to the countries of origin of the selected publications, as shown in Table 2.The origin of the articles was significantly focused on the United States.
We have identified only one article from a Brazilian journal.In other South American countries, we found no scientific literature on the subject in the period researched.Australia had two articles, and the European continent, though historically indicated as the "birthplace" of TCs, had no studies on the treatment of adolescents in such institutions.In relation to the methodology of analysis of the results, used to carry out the research, we found that four articles used the quantitative methodology and three the qualitative methodology.All studies that used quantitative methodologies are articles published by American authors.As a result, all articles that used qualitative methodology have been published by authors from other countries.
The quantitative method was identified as the preference to assess post-treatment results, that is, to verify the situation of adolescents after leaving the institutions.In the past, the qualitative methodology was mostly used to identify aspects of the process of treatment, from the perspective of the adolescent.
Considering such indication, we can assess that in American research studies, for the most part, we could identify a higher occurrence of studies using quantitative methodologies aiming at obtaining the analysis of the results after treatment.Such a condition may suggest the search for data that indicate the results of the care in TCs for adolescents, in order to answer a gap in this specific field (15) .
At the same time, other researchers presented an exploratory perspective of the subject, seeking to understanding the reality, especially from the perspective of the adolescents.Table 3 presents the methodology used and the period of treatment studied, 2002 -2013:

Central Subjects Identified in the Publications
The subjects were identified, grouped and discussed from the methodology proposed (12) .The ordering of the articles made possible the construction of Figure 1, from the articles included.
From the qualitative analysis of the articles found, we selected two central subjects: Subject one -Assessment and results of the treatment; Subject two -Aspects of the process of treatment.

Subject 1 -Assessment and results of the treatment
The studies related to this subject assess and monitor adolescents after finishing their treatment in TC, considering several aspects in addition to abstinence from PAS.The lack of studies on the effectiveness of the treatment in the therapeutic community is exposed, as well as the impossibility of generalization of the results, considering the heterogeneity of each service proposed (16)(17) .
The post-treatment monitoring and assessment is performed by a specific instrument and/or structured interviews, thus creating mostly quantitative studies.In addition to the abstinence from use, other aspects are also assessed in participants, such as physical and emotional health, participation in twelve-step groups, social network, risk behavior, engagement at work and school, recognition of the problem, among others aspects that may vary depending on the tool used.
The articles highlight the effectiveness of the proposed treatment in TC in some aspects of the adolescent life in relation to the abstinence from PAS use, but they reiterate the impossibility of generalization of these results to other institutions.In some cases, they report the improvement regarding use/abuse of PAS.However, this improvement cannot be applied to other issues such as involvement with crime and violent behavior.The studies confirm that the permanence in the treatment helps in the process of maintenance of abstinence even after they leave the program (16)(17)(18) .
The authors point out important issues to be included in the proposed treatment of adolescents treated in these institutions, with emphasis on the construction of an individual care plan/unique therapeutic project for each adolescent, paying attention to their needs from the physical and sexual violence suffered by them, in addition to considering the social and family context in which the adolescent was inserted (18)(19) .

Subject 2 -Aspects of the process of treatment
The studies classified under this subject show particular aspects of the process of treatment of adolescents in the space of the TC.They show the absence of research within this subject, as well as the even greater gaps in relation to studies which consider the perspective of the adolescent regarding the treatment that they are submitted (20)(21) .
The articles searched bring reports of experiences of adolescents on a daily basis in the TCs, which are considered as different spaces of health services and which allow change.They express issues of bonding and relationships among peers, such as social issues and their importance, and such relationships end up having a significant impact on treatment (20)(21)(22)(23) .In TCs, the relationship among peers is considered an essential part of the therapeutic monitoring (19) .
The studies show the strong bonds that are created between the adolescents, which at times acquire status of family processes, especially because many adolescents come from spaces where the family relationship, such as that experienced in TC, was restricted or even absent (23) .
The bonds built among the adolescents, during the period of care, can both positively and negatively contribute to the process of treatment, and these negative factors of the relationships among adolescents is little studied.
Most studies point to the neglect of the sexual activity, even though that is a determining factor for staying or not in the treatment.They have observed that sexual activity among adolescents is widespread, especially among females (22) .Although most TCs do not allow sexual activity during the period of treatment, the studies have observed that the adolescents develop sexual activity on a regular basis.The authors indicate the need for more openness for the discussion of such a subject.
They reiterate the importance of building an individual treatment plan, enabling the uniqueness of each situation.Factors such as treatment history, prior arrests, demographic data, family background and substance use should be considered for the construction of the individual plan for each treatment.
It is worth emphasizing the high number of adolescents referred by court order (20)(21)(22) and the fact that, for the most part, they are less motivated to undergo treatment and less willing to have a positive social interaction when compared to adults cared for in TC (20)(21)(22) , thus requiring greater post-treatment monitoring.
The distinction between the treatment of adults and adolescents is indicated as an important need to be observed.Models of care for adults that are also applied to adolescents do not have significant results.The care of adolescents in therapeutic communities is done, in most cases, applying the model of care for adults with "modifications" for this audience (15) .
In the care of adolescents, it is necessary to observe the characteristics of the age of such audience, aiming at training their skills to face life without the use of drugs, considering the time of formation and ressignification of their identities (24) .

Discussion
Studies on therapeutic community and addiction do not appear expressively in this review, especially when it comes to and their peculiarities, even if there is consensus in the literature of adolescents being a risk public regarding the use/ abuse of PAS (25)(26) .
Such paucity is even more significant when we talk about TCs with specific care for adolescents.The studies found are samples with very particular characteristics, which hinder the generalization of results (15) .We could not identify aspects of regularity, whether regarding years of publications, authors and journals.
Most publications are from the USA, as other studies, which also used a systematic review, have pointed out in previous moments (15) .The emphasis is seen on the Brazilian fragility in relation to the scientific literature on the subject.Such issue might lead us to think that this type of care, in the country, is being developed without being analyzed, studied and may even have been neglected.This condition is very worrying considering that we also have the care of adolescents in TCs in Brazil.
It is estimated that in Brazil, in some regions, approximately 80% of the population with disorders arising from the use/abuse of alcohol and other drugs are cared for in therapeutic communities (9) .However, it still is a challenge to measure the totality of care in these institutions considering the expansion of these services with few instruments of regulation or supervision.In this perspective, we are not considering whether the model offered by the TCs is resolute or not, but it seems clear that there is an urgent need to study, assess and consequently qualify this model.
The articles reviewed herein showed positive results in relation to adolescents treated in TCs, regarding PAS abstinence and the other areas of their lives also considered in the studies.At the same time, the same studies point out that they are inconclusive.The issue of generalization of the results, among other issues, does not seem to be possible, because the very concept of TC is not a consensus and it is much less generalized, especially regarding the service to adolescents.Thus, many studies eventually adopt such nomenclature, even if performing different activities than the methodology proposed in the creation of TCs in the '40s (4)(5)(6) .
In the articles researched, it is evident the recommendation made regarding the individualization of the service and the understanding of the particular needs of each adolescent.We highlight that this specific look for each one of them needs to be expanded to issues that go beyond the biological and social aspects and the model adopted, i.e. there is the need to cover the individuals in their entirety.The family, judicial, social and economic issues can be both positive and negative factors on treatment adherence.Therefore, they need to be considered when addressing adolescents.
The length of stay in treatment in TCs is related to better results, although the issue of adherence is still a major challenge.It stands out as a key element for the issue of motivation.The lack of perspective for the future and social and family support in the post-treatment does not assist in the motivation for change.The bonds formed between the adolescents and professionals are of great importance, sometimes being the primary instrument used.
In the articles studied, we found no references to any type of service offered to the families of the adolescents treated in the TCs.However, family care has been incorporated into TCs since the '70s, so that the family becomes co-responsible for patient care (5,27) .This element, important for the care, as a factor of great representativeness in the treatment, was not found clearly and recurrently in the articles (25)(26) .

Final Remarks
This work did not try to exhaust the discussion on the subject, but rather argue and discuss an issue of extreme importance, conveyed and discussed routinely by the spoken, written and televised press, both nationally and internationally.
Considering the growing expansion of this treatment in Brazil, it is important to know the TCs in the care of adolescents to understand their operation and enable the study and qualification of this service.We need to analyze, as it has been happening, their SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.jan.-mar.2016;12(1):48-57 effectiveness, efficacy and efficaciousness, without, however, ignoring this type of care, even if conceptual and/or methodological flaws can be identified.
Treatment in therapeutic communities for addicted adolescents is a challenge, considering the specific and particular needs of such age group in addition to the particularities of chemical dependency and the losses arising from to it.In addition to the treatment itself, other aspects need to be considered, such as: family care, social aspects, assessment of bonds, social reintegration, sexuality, among others.
One of the limitations of our review was the small number of articles found, relating TC and adolescents, proving that there is a scientific gap and an urgent need to develop further studies that may expand these and other aspects that have not been mentioned in these publications.
The treatment of persons with disorders arising from the use/abuse of alcohol and other drugs is provided for in the Brazilian health policy through RAPS (4) , which allows the care of these individuals in therapeutic communities.However, we could not see the discussion of such a reality in the articles found, which can denounce the absence of dialog in this network given the proposed treatment, specifically for the adolescent audience.
The subject studied is complex and its importance is unquestionable.It is evident the need for qualification of this type of service, so that adolescents have their needs addressed within a more inclusive model that considers the particularities and different types of therapeutic treatment.

Table 1 -
Distribution of articles selected according to database, 2002 -2013.

Table 2 -
Articles selected according to the country of publication, 2002 -2013