Distribution of SUS Procedures for Detection of Specific Learning Disorders (2016–2024)

Ana Priscila da Silva Teixeira; Alaina Alves

DOI: 10.22167/2675-6528-202602659

Article derived from a Course Conclusion Work (TCC), with content based on the student’s original work and adapted to the editorial format of the E&S Magazine with the support of the ResumeAI tool, an artificial intelligence solution developed by Instituto Pecege for textual synthesis and organization.

Summary

Specific learning disorders constitute a relevant challenge for educational development and for the effectiveness of school inclusion, demanding articulated responses between the health and education sectors. In the Brazilian context, the SUS plays a central role in the early identification of these conditions, through the offer of outpatient procedures aimed at investigating cognitive and linguistic functions. The present study aimed to characterize and analyze the distribution of records of these procedures in the SUS, by UF, in the period from 2016 to 2024. This is a descriptive and exploratory study, with a quantitative approach, based on secondary data from SIA/SUS, PNAD Contínua/IBGE, and the Atlas of Human Development in Brazil. The rate of procedures per 100,000 elementary school students was calculated, allowing for territorial comparisons. The results showed a continuous increase in the rates of procedures in the analyzed period, even with a reduction in the number of students, suggesting a relative expansion of investigative offer in the SUS. High regional heterogeneity was observed, with a concentration of higher rates in states with lower socio-educational development, without a statistically significant correlation with development indicators. The predominance of oral language assessment was also identified, indicating limitations in diagnostic diversity and interdisciplinary approach. The findings point to structural inequalities in access to specialized care and the need to strengthen primary healthcare, multiprofessional work, and intersectoral coordination with education. It is concluded that the qualification of the care network and the expansion of assessment strategies are fundamental to ensure timely diagnosis and promote educational inclusion.

Keywords: Learning; Early Diagnosis; Neuroscience; Unified Health System; Specific Learning Disorders.

1. Introduction

Learning is a complex and dynamic process, influenced by multiple cognitive, emotional, social, and environmental dimensions (CABRAL; CUNHA, 2024). Among the clinical conditions that affect this process, Specific Learning Disorder stands out, characterized by persistent and clinically significant difficulties in academic skills that last for at least six months, even after the provision of adequate interventions. These difficulties can include slow and inaccurate reading, impaired text comprehension, recurrent spelling errors, limitations in written expression, as well as deficits in number sense, calculation, and mathematical reasoning (APA, 2013). Of multifactorial origin, Specific Learning Disorder is influenced by the interaction between genetic, epigenetic, and environmental factors, which can affect the efficiency of central nervous system processing of verbal and non-verbal information (APA, 2013).

Learning disabilities represent relevant challenges for educational development and the promotion of inclusion, requiring a precise understanding of their nature and distinction from learning difficulties. While disorders stem from central nervous system dysfunctions, impacting cognitive processes and potentially having organic origins (LIMA et al., 2024; MOOJEN et al., 2016), difficulties tend to be associated with contextual factors, such as emotional, environmental, or methodological aspects. Alterations in cognitive functions, such as attention, memory, and perception, are frequently pointed out as relevant in cases of learning disabilities (Faria et al., 2019), which include conditions like dyslexia, dysgraphia, dysorthographia, dyscalculia, and language disorders. The diagnostic process for these conditions requires specialized evaluation to distinguish them from school-related difficulties.

The early identification of these disorders is crucial for specific guidance and interventions to be carried out as soon as possible, minimizing impacts on development and learning (LIMA et al., 2024). When difficulties are not recognized in a timely manner, they can accumulate throughout the school trajectory, widening academic gaps and hindering the learning of more complex content. Late recognition can also contribute to emotional distress, reduced self-esteem, stigmatization, and a higher risk of school dropout (SANTANA, 2021). In this context, the Unified Health System (SUS) plays a central role in the early identification of these conditions, through the provision of outpatient procedures aimed at investigating cognitive and linguistic functions (BRASIL, 1990). In line with this principle, the Multiannual Plan (2024–2027) foresees the expansion of equitable access to public policies, with the federal government being responsible for promoting integrated actions to reduce inequalities (BRASIL, 2023).

Despite the role of the SUS, the significant demand for diagnostic procedures can also be understood in light of the gaps in the training of Basic Education teachers. Studies show that a significant portion of educators feel insecure and unprepared to distinguish common learning difficulties from specific disorders (DIAS; MELO; PEREIRA, 2022). This insecurity in the process of identifying and managing these demands tends to result in poorly judicious referrals to health services, contributing to the overload of specialized care with cases that could, in large part, be resolved in the school environment itself. The literature indicates that access to specialized care is conditioned by challenges such as the geographical distance of services and inconsistencies in referrals and procedure coding, which can contribute to the fragmentation of flows and discontinuity of care (SILVA; MOREIRA, 2021). Health Surveillance plays a strategic role by producing and providing qualified and timely information through information systems, supporting decision-making and the improvement of public policies (BRASIL, 2023).

In this sense, knowing the distribution of procedures performed by the SUS is relevant to identify inequalities in the investigative offer and to support the planning of articulated responses between health and education, with a view to timely evaluation, adequate support, and school inclusion. Given the above, this study aimed to characterize and analyze the distribution of SUS outpatient procedure records for the detection of specific learning disorders, by Federation Unit, in the period from 2016 to 2024.

2. Material and Methods

The present study was characterized as a descriptive and exploratory investigation, with a quantitative approach, based on the analysis of aggregated secondary data. The research was conducted with the purpose of generating evidence on the distribution of outpatient records related to the detection of specific learning disorders, aiming to support intersectoral analyses between the fields of health and education. The central objective was to characterize and analyze the distribution of these procedures in the Unified Health System (SUS), by Federation Unit, in the period from 2016 to 2024.

For the study, data from three official public sources were used. Outpatient production was extracted from the SUS Outpatient Information System (SIA/SUS/DATASUS). Information on the estimated number of students enrolled in Elementary Education was obtained from the Continuous National Household Sample Survey (PNAD Contínua/IBGE). Additionally, data from the Atlas of Human Development in Brazil (PNUD) were used for contextual variables. The analysis period covered the years 2016 to 2024, excluding the years 2020 and 2021 due to methodological discontinuities in PNAD Contínua that could compromise the comparability of annual estimates.

Detailed data regarding outpatient production from SIA/SUS were formally requested from the Ministry of Health, through the Access to Information Law (LAI, Law No. 12.527/2011). The request specified the period of interest (2016-2024), the selection of procedures, aggregation by Federation Unit and competence year, and the exclusion of any individualized or identifiable information. The justification for the request was based on the public and collective nature of the data, in line with the principles of transparency and publicity of Public Administration.

The established unit of analysis corresponded to the Federation Unit (UF), with data structured and aggregated annually. The numerator of the indicator of interest was based on the sum of SUS outpatient procedures aimed at detecting learning disorders. Five specific procedures were selected, considered the main SUS outpatient evaluations aimed at measuring cognitive and linguistic functions underlying these clinical conditions, as described in SIGTAP.

Outpatient procedures included: application of a psychodiagnostic test (code 02.11.10.001-3), written/reading language assessment (02.11.07.006-8), oral language assessment (02.11.07.007-6), auditory processing tests (02.11.07.034-3), and school hearing screening (02.11.07.036-0). The denominator for the rate calculation corresponded to the estimated number of students enrolled in Elementary Education by State and year, extracted from PNAD Contínua (2022). The Municipal Human Development Index (IDHM) and its educational dimension (IDHM Education), both referring to the year 2021, were used as contextual variables for the exploratory analyses.

The organization and statistical analysis of the data were performed with R software (version 4.0). Initially, descriptive analyses were conducted, including absolute frequencies, volume by procedure type, and temporal variation of national and regional rates. Subsequently, the spatial distribution of records was examined, and territorial heterogeneity was measured by calculating the coefficient of variation (CV) among states.

To evaluate the exploratory relationship between the average rates of procedures and the level of socio-educational development of the Federative Units, Pearson’s (r) and Spearman’s (p) correlation tests were applied. The Pearson coefficient was used to assess the strength and direction of the continuous linear association between the variables, while the Spearman coefficient was employed as a complementary non-parametric measure. Bivariate analyses crossed the average rate of procedures per UF with contextual indicators (overall IDHM and IDHM Education of 2021), adopting a statistical significance level of p < 0.05. The interpretation of these metrics maintained an exploratory character, without presumption of causal inference.

The research was based exclusively on the use of secondary data, aggregated and devoid of individual identification. The databases used are publicly accessible, and their consultation and request can be made by any citizen, with only statistical information being made available. Due to these characteristics, the submission and prior approval by a Research Ethics Committee (CEP) were waived, in accordance with the provisions of Resolution nº 510/2016.

3. Results and Discussion

The analysis of the historical series of outpatient procedures for the detection of specific learning disorders in the Unified Health System (SUS), from 2016 to 2024, revealed divergent demographic and care trends. While the number of students enrolled in Elementary Education fell from 28.7 million to 26.5 million, the national rate of outpatient procedures per 100,000 students grew by a significant 41.7%. This growth, from 2,088.74 procedures per 100,000 students in 2016 to 2,960.05 in 2024, suggests a relative expansion of investigative supply within the SUS, even in the face of a reduction in the student population.

Despite the general trend of growth in the rates of procedures registered in the SUS, a notable heterogeneity was observed in the regional trajectories over the analyzed period. The North region, for example, presented the lowest rate among the macro-regions in 2016, but demonstrated progressive growth until 2019. In the resumption of the historical series, after the exclusion of the years 2020 and 2021 due to methodological discontinuities in PNAD Contínua, a new increase was identified between 2022 and 2023, followed by a reduction in 2024. Similar oscillations were observed in other regions, such as the sharp increase in the Center-West in 2018, indicating that the expansion of procedure rates did not occur continuously or uniformly throughout the national territory.

The spatial distribution of outpatient procedure records showed marked regional inequalities. A concentration of high average rates was observed in federal units such as Maranhão, Mato Grosso, and Rondônia, which presented the highest average rates of procedures per 100,000 students. In contrast, states like Acre, Piauí, and Tocantins registered a low occurrence of procedures, possibly associated with underreporting phenomena. This geographical disparity suggests that access to specialized services within the SUS is conditioned by structural determinants of the healthcare network itself, in addition to operational barriers in healthcare regulation.

To investigate the relationship between these disparities and the levels of socio-educational development, the average rates of procedures were crossed with the Municipal Human Development Index (IDHM) overall and the IDHM Education. The results did not indicate a statistically significant correlation between the volume of services and these development indices, with a Pearson coefficient of 0.18 for IDHM Education and 0.04 for the overall IDHM. This finding reinforces the hypothesis that the observed differences in the distribution of procedures are more related to the organization, installed capacity, and access flows of the healthcare network than directly to the socio-educational conditions of the population.

The heterogeneity in the distribution of procedures, therefore, reflects challenges in the organization and installed capacity of the healthcare network. The literature indicates that access to specialized care is often hindered by factors such as the geographical distance of services and inconsistencies in referrals and procedure coding, which can lead to fragmented flows and discontinuity of care (SILVA; MOREIRA, 2021). In this context, Primary Health Care (PHC) assumes a central role as the organizer of care and coordinator of the Health Care Network, with multidisciplinary teams playing a strategic role in qualifying the management of demands within the territory.

Beyond territorial inequalities, the results indicated expressive differences between the types of procedures registered. Oral language assessment predominated, corresponding to a significant portion of national records, ranging from 50.4% to 62.5% in the analyzed period. In contrast, psychodiagnostic assessment showed a relative reduction in its participation, and auditory screening did not exceed 6.1% of the total procedures. This predominance of oral language assessment was the most registered procedure in most federative units, as evidenced in the distribution by UF.

The high concentration of records in oral language assessment can be explained by multiple assistive and operational factors. This includes the presence of qualified professionals and the installed capacity of services for this type of assessment, as well as the relative ease with which family members and educators identify speech alterations. However, differences in referral criteria, inequalities in the distribution of specialties, and discrepancies in billing via SIGTAP and SIA/SUS also contribute to this scenario. More complex assessments, such as psychodiagnostics and auditory processing investigation, require more time, specific infrastructure, and specialists, which limits their regional availability.

The centralization of assessments in the dimension of oral language may, however, limit the identification of more complex neurobiological frameworks, as low school performance is not restricted to linguistic deficits. Recent studies attest to the high comorbidity rate of learning disorders with Attention Deficit Hyperactivity Disorder (ADHD), intellectual disability, and internalizing conditions, such as childhood anxiety and depression (PATERLINI et al., 2019). A comprehensive etiological investigation requires the articulated action of multidisciplinary teams and the systematized use of instruments that assess cognitive aspects, executive functions, and behavioral dimensions (FERRARI, 2025; PINHEIRO; MARQUES; LEITE, 2018).

Learning to read, write, and perform mathematical reasoning depends on an integrated network of neuropsychological skills that operate in parallel and can be impaired even in children with typical speech and receptive vocabulary development (ZUANETTI et al., 2018). A student may exhibit fluent verbal communication and still show severe deficits in executive functions, such as inhibitory control and cognitive flexibility, or in working memory, compromising the planning of complex tasks and academic performance (SIQUEIRA; GURGEL-GIANNETTI, 2011). Limiting the investigation to oral speech-language pathology assessment, therefore, can create a blind spot in diagnosis, preventing the identification of essential cognitive and motor dysfunctions (MÉLO et al., 2020).

The expressive demand for diagnostic procedures can also be understood in light of the gaps in the training of Basic Education teachers. Studies show that a significant portion of educators feel insecure and unprepared to distinguish common learning difficulties from specific disorders (DIAS; MELO; PEREIRA, 2022). This insecurity in the process of identifying and managing these demands tends to result in poorly judicious referrals to health services, contributing to the overload of specialized care with cases that could, in large part, be resolved in the school environment itself, through the adoption of qualified pedagogical strategies and targeted educational interventions.

In this sense, reducing the historical distance between the clinical and pedagogical fields, as well as qualifying referrals, demand the effective implementation of intersectoral policies. The School Health Program (PSE), established in 2007, is an interministerial articulation initiative between the Ministry of Health and the Ministry of Education, configuring itself as an intersectoral and interdisciplinary strategy. Its objective is to promote comprehensive health care for children and adolescents enrolled in the public school system, through the joint action of Primary Health Care teams, basic education, and the school community (BRASIL, 2007).

The articulation between the health and education sectors, promoted by programs such as PSE, favors the construction of more structured communication tools and the qualified exchange of information between teachers and health teams, expanding the conditions for more contextualized assessments (SILVA, 2023). However, the expansion of diagnostic procedures in the public network will only produce concrete effects on the school trajectory when articulated with the implementation of inclusive interventions. The identification of a learning disorder demands that the school institution move beyond an approach centered on deficit and advance towards a social model of inclusion, materialized by instruments such as the Individualized Education Plan (IEP) or the Individual Development Plan (IDP) (RAFAGNIN; RODRIGUES; KOSLOSKI, 2020).

It is important to consider the limitations inherent in the use of secondary administrative data, such as those from the SUS Ambulatory Information System (SIA/SUS). These data reflect the production of procedures performed in health services and do not necessarily correspond to the occurrence of confirmed diagnoses, as there is no mandatory link between records and specific diagnostic codes. The possibility of underreporting and the supply bias, resulting from the higher concentration of services in certain regions, can influence the observed distribution. Furthermore, the use of population estimates as a denominator may introduce variations in the calculated rates over the period.

In summary, the results of this study show that the investigative supply of procedures for detecting learning disorders in the SUS has expanded, but heterogeneously among the federative units, reflecting structural inequalities in access to specialized care. The absence of a statistically significant correlation with socio-educational development indicators suggests that disparities are more related to the organization and capacity of the health network. The predominance of oral language assessment points to the need for diversification of evaluation methods and strengthening of multiprofessional and intersectoral action, aiming to ensure timely diagnosis and promote educational inclusion.

4. Conclusion

The present study characterized and analyzed the distribution of outpatient procedure records from the Unified Health System (SUS) for the detection of specific learning disorders, by Federation Unit, in the period from 2016 to 2024. A continuous growth in the rates of procedures per 100,000 elementary school students was observed, which increased by 41.7% during the period, even with a reduction in the number of students, suggesting a relative expansion of investigative supply. However, a high regional heterogeneity was observed in the distribution of these procedures, with higher rates concentrated in states with lower socio-educational development, although no statistically significant correlation was identified between the volume of care and human development indicators. Additionally, the predominance of oral language assessment among the registered procedures was identified, indicating possible limitations in diagnostic diversity and the scope of the interdisciplinary approach. The main contribution of this work lies in highlighting the structural inequalities in access to specialized care and the need for qualification of the healthcare network to ensure timely diagnosis and promote educational inclusion.

It is essential to consider the limitations inherent in the use of secondary administrative data from the SUS Ambulatory Information System (SIA/SUS), which reflect the production of procedures and not necessarily confirmed diagnoses, given the absence of mandatory linkage to specific diagnostic codes. The possibility of underreporting and the supply bias, arising from the concentration of services in certain regions, may have influenced the observed distribution, and the use of population estimates as a denominator introduces variations in the calculated rates. In light of these findings, the strengthening of Primary Health Care (PHC) as the coordinator of care, the qualification of multiprofessional practice, and the expansion of evaluative strategies that encompass the complexity of learning disorders are recommended. It is also suggested to intensify intersectoral coordination between health and education, through programs such as the School Health Program (PSE), aiming to improve referrals and the implementation of inclusive interventions that go beyond a deficit-centered approach, materialized by instruments such as the Individualized Education Plan (IEP) or the Individual Development Plan (IDP).

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