Child and adolescent mental health, as an essential component of overall health, has gained increased recognition worldwide. In part, this recognition derives from concerns about the mental health consequences of war, prolonged conflict, natural disasters, AIDS and substance abuse. Furthermore, there is an increased understanding that children who are not mentally healthy can have an adverse impact on the stability and economic viability of nations. Media reports of new knowledge about the nature, etiology and treatment of childhood mental disorders have been important contributions to this increased knowledge.
However, the recognition has not brought forth the economic and human resources necessary to meet the observable need. The reasons for this gap are several and include the world's ambivalent view of the worth of children in societies: the view of children as family property to be used for work, a lack of comprehension that children have a mental life and a failure to understand developmental psychopathology. Only now, with progress being made toward the eradication of infectious diseases and the improvement of nutritional status in many societies, may it become possible to consider the mental health of children as a priority issue and provide needed resources. The U.N. Convention on the Rights of the Child is also providing a framework by which to consider equity for those impacted by child and adolescent mental disorders. The Convention has stimulated dialogue and program changes, leading to a reduction in barriers to care, increased support for families, and increased the opportunity for children and adolescents with mental disorders to reach their full potential. More information is available at <www.unicef.org/crc/introduction.htm>.
Child Mental Health ProblemsDetermining the epidemiology of childhood mental disorders is a challenge throughout the world. Reporting systems are inadequate, the definition or recognition of disorders varies or has variable interpretations, and the cultural component of what constitutes a disorder is only now being more fullyappreciated by epidemiologists and researchers. In studying the epidemiology of psychiatric disorders in children and adolescents in developing and developed countries, it is important to define not only the prevalence and incidence of the disorders, but the associated burden of disease, measured in terms of cost of care over the life span and loss of human potential.
World Health Organization (WHO) studies of primary care clinicians in the 1980s showed that a significant proportion of patients seeking care had mental disorders and that their communities were aware of the problem. Giel and Van Luijk (1969) found, counter to prevailing beliefs, that mental disorders were diagnosed more frequently than infectious diseases in four health centers in Africa. However, there has been no single study or consistent set of independent studies on the epidemiology of child and adolescent disorders in the past 20 years that can be identified as definitive or relevant across societies. Those studies carried out 20 years ago have methodological deficiencies and certainly do not reflect the current realities of the countries from which the data were reported. Fayyad and colleagues (2001) summarized the significant international epidemiological studies and concluded that the range and rates of psychiatric symptomatology in children in developing countries are similar to those in the developed world. There appeared to be universal risk factors and culture-specific factors that correlated with manifest psychopathology. A number of investigators have found that mental health symptoms in children do not differ significantly across cultures and that culture-specific mental health disorders are rare. These views of comparability with Western epidemiological data are at odds with older studies and may reflect new social and economic realities. This does not mean to imply that the current classification of disorders is universally supported. In developing countries in particular, there is a call for broader categorization to enable less well-trained individuals to better utilize diagnostic systems in their work.
Most countries today have access to appropriate epidemiological study guidelines, and it will be a matter of setting national priorities and allocating resources to ascertain the data in developing countries. The recent delineation of cultural epidemiology by Weiss (2001) combined classical epidemiology with information derived from cultural anthropological study. Cultural epidemiology offers a unifying approach that may advance the understanding of child and adolescent disorders as seen in developing countries and inform our understanding in clinical settings worldwide.
What of the disorders that are now occupying considerable attention in developed countries, such as attention-deficit/hyperactivity disorder, autism and anorexia nervosa? The diagnosis and treatment of these particular disorders highlight both the strengths and weaknesses of having an international perspective. The recognition and labeling of these disorders came as a result of improved international communication. However, the process of assessment needs added sophistication to take into account cultural concepts of what is normal or abnormal and how parents and others perceive the presence or absence of a diagnosable disorder. In the case of eating disorders, as noted by Becker (1995), evidence suggests that the incidence in developing countries may be affected by Western influences. Thus, there is little doubt that these disorders are seen, but what should be the level of resources invested in the treatment of these disorders in countries that have little access to the medications or programs that might be indicated?
Increasingly, it is the pharmaceutical industry that provides local education to health care providers in countries throughout the world. The attendant focus on particular disorders of interest to the pharmaceutical industry, through direct advertising to the public, may distort the presentation of children and adolescents for treatment in clinics and lead to misconceptions about the incidence and prevalence of disorders. In addition, there may be a variety of incentives for the over-diagnosis of disorders such as ADHD.
Concerns About Care