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.
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.1 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.2 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 (Table).3 Key to these global difficulties is the absence of government policies.
Early interventions are crucial
Heckman and colleagues4 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.2,5 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 14.5-7
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.8 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.8,9
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 (Table). 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.10 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.11
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.12
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.13,14 The situation for child psychiatry is far worse than for adult psychiatry, and even that shows a dramatic gap in resources versus need (Figure). 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.15 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 can be done?
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.17 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.18
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.
1. UNICEF. 2008. Statistics and monitoring. http://www.unicef.org/statistics. Accessed January 16, 2014.
2. Kieling C, Baker-Henningham H, Belfer M, et al. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011;378:1515-1525.
3. Belfer ML. Child and adolescent mental disorders: the magnitude of the problem across the globe. J Child Psychol Psychiatry. 2008;49:226-236.
4. Carneiro P, Heckman JJ. Human capital policy. In: Heckman JJ, Krueger A, eds. Inequality in America: What Role for Human Capital Policy? Cambridge, Mass: MIT Press; 2003.
5. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6:168-176.
6. Reef J, Diamantopoulou S, van Meurs I, Verhulst F, van der Ende J. Predicting adult emotional and behavioral problems from externalizing problem trajectories in a 24-year longitudinal study. Eur Child Adolesc Psychiatry. 2010;19:577-585.
7. Copeland WE, Adair CE, Smetanin P, et al. Diagnostic transitions from childhood to adolescence to early adulthood. J Child Psychol Psychiatry. 2013; 54:791-799.
8. Eisenberg L, Belfer ML. Prerequisites for global child and adolescent mental health. J Child Psychol Psychiatry. 2009;50:26-35.
9. Rutter M. Categories, dimensions, and the mental health of children and adolescents. Ann N Y Acad Sci. 2003;1008:11-21.
10. UNICEF. United Nations Convention on the Rights of the Child. http://www.unicef.org/crc. Accessed January 16, 2014.
11. Belfer ML, Saxena S. WHO Child Atlas project. Lancet. 2006;367:551-552.
12. Maj M. “Psychiatric comorbidity”: an artefact of current diagnostic systems? Br J Psychiatry. 2005;
13. World Health Organization. The World Health Report 2001 – Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001.
14. World Health Organization. Project Atlas: Mental Health Resources in the World 2001. Geneva: World Health Organization; 2001.
15. Waitzkin H, Jasso-Aguilar R, Iriart C. Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School. Int J Health Serv. 2007; 37:205-227.
16. World Health Organization. WHO MINDbank. http://www.who.int/mental_health/mindbank. Accessed January 16, 2014.
17. World Health Organization. Caring for Children With Mental Disorders: Setting WHO Agenda. Geneva: World Health Organization; 2003.
18. Carlson M, Brennan T, Earls F. Enhancing adolescent self-efficacy and collective efficacy through public engagement around HIV/AIDS competence: a multilevel, cluster randomized control trial. Soc Sci Med. 2012;75:1078-1087