Myron L. Belfer, MD, MPA

The goal of ensuring child and adolescent mental health, while much discussed, is elusive. There are 2.2 billion children and adolescents in the world, most of whom live in suboptimal conditions that greatly reduce their chances for a productive and satisfying life.

 Assaults on the mental health of these youths are numerous, yet support systems for this vulnerable population are often absent.

One could argue that in the past 50 years, the basic elements of ensuring mental health for children have been eroded rather than enhanced. Granted, much more is known about brain development, and cognitive neuroscience is exploring how the brain works. There is also an increased awareness of the importance of good mental health for a child’s optimal development and secure future. However, it is equally clear that the support of families has in many cases been eroded by the stresses of modern life, that there is less tolerance for differences despite rhetoric to the contrary, and that services are less available and more expensive than in the past. The current interest in seeing child mental health services provided in “collaborative care” or a “medical home” model has yet to prove feasible, given financial and professional resource constraints.

Global child mental health in low- and middle-income countries faces all of the challenges of Western society and many more.

 Barriers to care are evidenced at every turn, whether it be the lack of trained professionals, cost constraints that limit access to services, stigma, or lack of effective treatments (

 Key to these global difficulties is the absence of government policies.

 showed the overwhelming cost-effectiveness of early intervention. Using data from the Perry Preschool Project, they demonstrated that early intervention provided the greatest cost benefit. However, history shows that child mental health services are often the first to be cut in times of fiscal crisis. Structural factors and obsolete notions about care and the capacity of children to have a mental life have led to this state of affairs.

Mental health problems account for a vast proportion of the global burden of disease. A diagnosable mental disorder is present in at least 10% of all youths and represents a leading cause of health-related burden worldwide among young people aged 10 to 24 years.

 At the same time, a growing body of evidence indicates that a substantial proportion of psychiatric diagnoses identified in adults have their roots in childhood and adolescence. Upward of half of all adult mental disorders begin before the age of 14.

Because child mortality has dramatically decreased in most regions of the world and infectious disease is being displaced by chronic illness, mental health as a component of health care is becoming a central focus of concern. We can no longer think of child mental health issues as arising in the school years but must consider disorders such as autism and depression manifesting in the preschool child.

There is no common frame of reference and understanding between medical clinicians and mental health professionals. Understanding the relationship of mental health to physical health has been hampered by a lack of sharing of research data, a disconnect in terminology, and assumptions about negative outcomes from mental health interventions. The incentives for primary care clinicians to embrace mental health concerns simply do not exist in the current global economic and practice climate. Yet, the dilemma for primary care providers is that mental health directly affects adherence to medical regimens and influences risky behavior leading to disease and possibly premature death.

While much has been discussed about the importance of the primary care clinician as the focal point for triage and intervention, the knowledge of how and when to provide education is largely lacking or unproven.

 Inadequacies in training are repeatedly documented, and the reluctance of primary care providers to take on the added role of child mental health triage is seen everywhere. Rarely does a pediatrician or other primary care clinician or a teacher want to be identified as a specialist in mental health. Creative efforts using telepsychiatry, which can maximize the use of more specialized mental health providers in the primary care setting, are in their infancy.

The recognition that cognitive achievement is essential for a successful life and that IQ alone is not an adequate measure must be incorporated in policies at all levels of society. The emotional life of children influences and is influenced by the child’s state of physical health. Moreover, diagnosis in children is a dynamic process, and currently available tools may be inadequate to predict problems.

Today, children face a highly competitive society. The expectations for child educational achievement in most societies have risen over the decades, bringing into consideration factors heretofore isolated from the mainstream of child health. The increasing demands for intellectual performance rather than physical prowess define group differences in ways not previously conceptualized, and alternatives become increasingly narrow for those who are intellectually and mentally challenged.8 Thus, there is a paradox in the rhetoric about decreasing the isolation of children and adolescents with mental disorders and society’s demand for greater intellectual attainment and better mental health.

Governments lack the policies needed to ensure stable, adequate funding for child mental health (

). Too often, governments rely on unregulated, uncoordinated, short-term non-governmental organization (NGO) support for programs and equate ratification of the United Nations (UN) Convention on the Rights of the Child with meaningful support for child mental health, which it is not.

 NGO initiatives, while well intentioned, have been shown to have a variety of negative consequences that offset positive contributions. Some of these initiatives might include:

• Interventions that do not fit with local culture and/or that are not evidence based

• Jobs at unsustainable levels of compensation, which lead to individuals who no longer pursue sustainable occupations

• Cash payouts that go for non-essential and sometimes destructive purchases

Moreover, the UN Convention on the Rights of the Child is rarely implemented in the ways that would ensure nonstigmatized access to care, inclusion, and participation.

The application of multiple diagnoses with inadequate documentation and the off-label use of multiple medications are problems that plague child and adolescent psychiatry worldwide. Current diagnoses and psychotropic medication prescription practices are manifestations of our gap in knowledge about the disorders being treated. Mario Maj, MD, a former president of the World Psychiatric Association, was forthright in his identification of this problem in a British Journal of Psychiatry editorial and in his presidential address.

This is even more of a problem in many low- and middle-income countries and in rural regions in Western countries with reduced mental health resources, which-in the absence of other means of care-lead to poor diagnostic capabilities and a reliance on medication, and undue influence from the pharmaceutical industry. Unfortunately, the same can be seen in the midst of sophisticated diagnostic and treatment resources when clinicians attempt to be “scientific” in their approach and ignorant of clinical realities. For example, the same symptoms associated with ADHD can be associated with psychosis, an anxiety disorder, or some forms of neurodegenerative disease.

From a global perspective, it is unrealistic to assume any major changes in the number of child psychiatrists, and this in itself would not address the mental health needs of the most vulnerable populations.

 The situation for child psychiatry is far worse than for adult psychiatry, and even that shows a dramatic gap in resources versus need (

). The American Academy of Child and Adolescent Psychiatry has approximately 8000 members. The rest of the world has, at most, approximately the same number. In low- and middle-income countries, many who identify themselves as child and adolescent psychiatrists have a minimum of training. What is needed is a healthy dose of reality testing that recognizes the importance of accurate diagnosis, evidence-based medications, and recognition of the long-term, serious effects of childhood mental disorders.

Structural and financial changes that enhance capacity are needed. These could be accomplished by training health care professionals in other specialties to assist in the diagnostic process and treatment (eg, autistic children can be treated in community settings, meaningful work programs can be provided for persons with developmental disabilities, primary care clinicians can routinely screen for psychiatric disorders).

Task shifting, distance learning, teleconferencing, teletherapy, and other forms of education and therapy that do not rely on costly and scarce traditional child mental health professional resources are being considered. However, each of these strategies produces its own challenges.

• Who provides the initial quality education to the “master teachers”?

• How are treatments selected and who makes the treatment decisions?

• Who is responsible for quality control and determining the long-term benefits of the treatments used?

Furthermore, there may not be any significant financial gains from the proposed strategies. It is conceivable that with experience the computer-based interventions and the telemedicine approaches may make mental health care more accessible and reduce costs, but this has yet to be proven.

Rather than expanding community-based education about mental health and providing easily accessible childhood mental health monitoring as part of general health care, governments are focused on privatization, which is altering the landscape of services. The World Bank has encouraged privatization in developing countries in accord with a policy of structural realignment.

 In Africa and South America, the impact has too often been a dismantling of sustainable public health programs. In Eastern Europe, Asia, and other low-income regions of the world, the lure of insurance payments has drawn the most experienced clinicians out of public sector jobs into private practice, thus eroding already inadequate systems of care.

Natural and man-made disasters, war, and famine have had devastating effects on children and adolescents. Not only is there the obvious associated mortality but the psychological morbidity has immediate and long-lasting consequences. The current emphasis either on resilience or PTSD has negatively affected the development of more comprehensive mental health services and systems of care. The rote utilization of psychosocial interventions (that are often not evidence based) for PTSD as an alternative to clinical care has reduced the types of interventions being offered-psychosocial interventions are not a substitute for the ability to make a psychiatric diagnosis for depression, suicidality, psychosis, and developmental disabilities.

What are the short- and long-term solutions? It is quite presumptuous to think that I have an answer. Policy and educational reforms have a key role to play. Policy can support engagement through both incentives and coercion, and training can lessen the emotional barriers to engagement. Economic data are available that show the consequences of the failure to provide services and prevention efforts to support child and adolescent mental health. Governments must become more aware of these data and see more clearly the consequences for society when good child mental health is not achieved.

More holistic cross-disciplinary training not unlike that of 50 years ago would help with the current shortage of trained individuals to deliver interventions. The sharing of best practices as now offered in an accessible way through the World Health Organization (WHO) MINDbank16 platform and the wider dissemination of evidence-based diagnostic processes and interventions is a step forward. “Rational care” (a term used by the WHO) emphasizes care that focuses on the needs of the child and family in a community context and offers treatments that are accessible and feasible.

 A focus on rational care would lead to a reduction in polydiagnosis and polypharmacy.

Mental health is an essential element of ensuring stable and productive societies regardless of income level or developmental state. Much can be done, but the political will to achieve positive outcomes needs to be mobilized. Bolder action, better integration of knowledge, and a recognition of the advances in neuroscience are needed to achieve the goal of improved mental health for all children. The future needs to embrace the full range of entitlements of the UN Convention on the Rights of the Child and give to children and their families the necessary conditions to foster self and collective efficacy, the ability for individuals and communities to take action on their own behalf and for others.

This article was published online ahead of print, on 2/14/2014.

Dr Belfer is Professor of Psychiatry at the Boston Children’s Hospital, Harvard Medical School, Boston. He reports no conflicts of interest concerning the subject matter of this article.

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Articles

Global child mental health in low- and middle-income countries faces all of the challenges of Western society and many more. This article examines the issues. 

Global Child Mental Health

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>.

Determining 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 

 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. 

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

 Becker AE (1995), Body, Self, and Society: The View From Fiji (New Cultural Studies). Philadelphia: University of Pennsylvania Press.


 Fayyad JA, Jahshan CS, Karam EG (2001), Systems development of child mental health services in developing countries. Child Adolesc Psychiatr Clin N Am 10(4):745-762, ix.


 Giel R, Van Luijk JN (1969), Psychiatric morbidity in a small Ethiopian town. Br J Psychiatry 115(519):149-162.


 Weiss MG (2001), Cultural epidemiology: an introduction and overview. Anthropology Med 8(1):5-29.

Despite increased knowledge of child and adolescent mental health disorders worldwide, there is still a dearth of economic and human resources available to meet treatment needs, especially in developing countries. In this article, the impact of developed countries and the dimensions of this problem are discussed.

Myron L. Belfer, MD, MPA

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