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

April 15, 2004
Myron L. Belfer, MD, MPA

Volume 21, Issue 5

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.

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 Problems

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 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

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.

Manpower Issues

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).

Impact of International Issues

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.

Conclusions

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

References:

References


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

2.

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.

3.

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

4.

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