Setting Priorities: The Status of Child Mental Health Care Around the World

While it is now common in the United States to focus on the development of "systems of care" for children with mental disorders, in the developing world, the concept is not as well-understood and even more difficult to consider implementing. Too often, countries have been dependent on inpatient care in institutions that lack quality control and use antiquated methods of care. Today, with better communication about modern modes for effective treatment that are not based solely in hospitals, a better balance in the provision of humane care is now the goal in most countries. Of course, the ability to achieve this goal is limited by financial constraints and lack of trained professionals.

The trend toward "privatization" is visible throughout the world. This might be seen as progressive, but in resource-poor countries the move away from state-subsidized care toward private care is leaving many without any care. Human resources are being drained from the care network as professionals move into private practice. Governments are also adopting managed care and various insurance schemes without understanding the negative consequences that have been observed in the West. In countries with more resources, the inclusion of child mental health services in insurance plans would be a progressive step as long as it led to an increase in the number of covered individuals and an appropriate level of care and range of services. In developing countries, however, the low resource base and the already marginal financial support for insurance make both of these concepts ill-advised.

In times of natural disaster or in the aftermath of war, developing countries have experienced an influx of non-governmental organizations (NGOs). While the services provided by NGOs are often an important resource, the lack of coordination, lack of cultural appropriateness and lack of provision for sustainability after the crisis can lead to detrimental consequences. The absence of needs assessment and the "one size fits all" approach lead to inappropriate care. These emergency interventions can also potentially disrupt rational service and training development.

Child and adolescent psychiatrists are a rare commodity in developing countries. Other trained child mental health care professionals vary in number and distribution in these countries, but the numbers are almost universally inadequate. Thus, the mode of practice often differs from that in more developed countries with an increased emphasis on the use of primary care health providers, family and non-familial community members, traditional healers, and religious leaders. In countries where child psychiatry is a very scarce resource, there may only be the opportunity for a consultative role, limited diagnostic capability and an inability to play a role in the development of national policy. At the same time, however, child and adolescent psychiatrists involved with developing countries may play a vital role in educating other professionals in medicine, psychology, education, social work, nursing and the volunteer community. The development of training programs is a priority for many organizations involved with child mental health care in developing countries. Innovative training for adult psychiatrists and primary care providers has been developed and implemented in many regions of the world. It is particularly important that the competencies of child and adolescent mental health clinicians fit the needs of the societies in which they exist (i.e., epilepsy and mental retardation clearly fall within the expected clinical competencies of child and adolescent psychiatrists in many countries, but are not expected competencies of child and adolescent psychiatrists in developed countries).

Child and adolescent psychiatrists, other child and adolescent mental health care professionals, and those involved with family treatments need to be aware of the global issues impacting the mental health of children. Increasingly, in the United States and other countries around the world, immigrant populations are presenting with child and adolescent mental health problems that are a direct extension of the traumatic experiences in their home countries, compounded by the difficult task of making adjustments in a new country. It is now well-documented that immigrants are more likely to present with symptoms of disorder more akin to that seen in their country of origin than in their new country of residence. Thus, a cultural literacy among domestic providers is becoming a very important part of training and clinical practice. Of particular import is the need to be aware of the suicide potential in these populations as they face a variety of stresses in their new environments and residual distress from their past experiences.

Improved communication of modern concepts about child and adolescent mental disorders, the need to address pressing national problems impacting youth, and the awareness of the empowerment provided by the U.N. Convention on the Rights of the Child has propelled child mental health care into a new era. With this progress, there is the caution to keep a focus on the provision of "rational care," implying the provision of appropriate care following appropriate diagnostic procedures. There is the obligation not to exploit the vulnerable populations of children and adolescents with mental disorders and their families through false promises of treatment benefits from ill-proven interventions.

Ideally, supporting child mental health care would be synonymous with prevention activities. Unfortunately, prevention efforts have lagged in operationalizing concepts, convincing funders of the need for long-term support and embracing what is now understood about developmental psychopathology. The hope for the future is that prevention efforts can be a more central part of efforts to support child mental health care. This, along with an increased understanding of the genetics and biology of disorders, holds promise for an exciting era for child mental health care globally. See Table of Related Organizations