What are the principles that should guide mental health policies in countries of low and middle income?

EDITORIAL

The development of effective mental health policy in and of itself does not cost money. The models for policy development exist.¹ Naïveté on the part of politicians, old notions of mental disorder and care, stigma, and lack of political will are the barriers to policy development. Governments try to escape the development of infant, child, and adolescent mental health policies by claiming that all policy considerations are covered by the UN Convention on the Rights of the Child. Ratification of the UN Convention on the Rights of the Child is virtually universal, but the mental health of children has not benefited from its provisions in most countries.²

We know now that over half of all adult mental illness begins before age 14.³ Further, it is known that the cost of child and adolescent mental disorders is significant. Increased costs are evident in the excessive utilization of health care services and the juvenile justice system.^4-6 The effectiveness of specific prevention programs can now be documented. For instance, the family intervention for maternal depression has had impressive results in diminishing mental health morbidity in families and among youth.⁷ The trend in low- and middle-income countries to emulate more resourceful rich countries by the establishment of specialized clinics and training for diagnoses such as PTSD, ADHD, and autism is problematic. These specialized clinics tend to divert resources from the development of more comprehensive service delivery mechanisms. They tend to emphasize sub-specialty training within the broader specialty of child psychiatry and prematurely label children with a diagnosis that results in adverse consequences for education and care. These sub-specialty clinics and clinicians bypass a broader, more accurate diagnostic assessment.

Brazil has led the way in the development of initiatives that could greatly aid the development of infant, child, and adolescent mental health services. The implementation of Guardianship Councils has provided a mechanism for advocacy essential for any national policy to be effective.⁸ Further, Brazil has pioneered in early diagnosis through innovative strategies using immunization as a means for providing a platform for screening for potential mental health problems in infants (Celia Salvador, personal communication). Support for child mental health training and delivery of care in primary care settings holds promise in low- and middle-income countries. There, professional specialty manpower needs related to child psychiatry and child psychology, at this point in time, cannot be met.

Principles that emerge from the observations above:

1) A rights-based approach to care that provides the opportunity for the most marginalized to participate in society.⁹ This will require rethinking about the concepts of impairment and inclusion.

2) Empowerment (agency) for youth. Countries in Latin America have a preponderance of young individuals. In order to avoid destabilizing social upheaval, often led by individuals who have suffered from ill mental health and marginalization, it is necessary to give youth a voice and to offer them the opportunity to be gainfully employed and to have a future. Brazil's rights programs are a possible model.

3) Enhanced efforts at increasing the awareness in relation to infant, child, and adolescent mental health. These should not be special programs, but should be fully integrated into public health and educational initiatives. Targets should be parents, policymakers, educators, and clinicians.

4) Parenting must be seen as a major factor in providing the basis for the future development of children and, ultimately, of society. Thus, women must be valued and given the means to be self-sufficient in the absence of other support.

5) Universal education must mean just that. Too often universal education is a concept more than a reality. Uniform fees, book fees, and transportation barriers keep children from entering and sustaining their rightful education. Without education youth are vulnerable to mental ill health growing up and the opportunity for school-based mental health services for vulnerable children is missed.

6) A balanced system of child mental health services located in the community and offering a broad range of diagnostic and treatment services needs to be supported.¹⁰

None of the articulated principles represent program initiatives that call for major financial investments, rather they call for a re-orientation to the approach of assuring child mental health. Incremental advances in all these areas could be measured and the arguments then made to sustain the efforts.

A failure to address child mental health needs is now being recognized worldwide as a major vulnerability for societies in the 21^st century.

Myron L. Belfer

Harvard Medical School, Boston, Massachusetts, USA

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References

• ¹
  1 World Health Organization. WHO Atlas for country resources for child and adolescent mental health 2004. [cited 2010 Feb 16]. Available from: www.who.int/mental_health/evidence/atlas/
• ²
  2. World Health Organization. WHO mental health policy and service guidance package: child and adolescent mental health policy and plans. Geneva: World Health Organization; 2005.
• 3. Kessler R, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün TB. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. 2007;20(4):359-64.
• 4 Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O'Brien PC. Use and costs of medical care for children and adolescents with and without attention-deficit/hyperactivity disorder. JAMA. 2001;285(1):60-6.
• 5 Scott S, Knapp M, Henderson J, Maughan B. Financial cost of social exclusion: follow up study of antisocial children into adulthood. BMJ. 2001;323(7306):191.
• 6. Knapp M. The cost consequences of conduct disorder. Mental Health Res Rev. 2000;7:8-10.
• 7. Gladstone TR, Beardslee WR. The prevention of depression in children and adolescents: a review. Can J Psychiatry. 2009;54(4):212-21.
• 8. Belfer ML, Rohde LA. Child and adolescent mental health in Latin America and the Caribbean: problems, progress, and policy research, Rev Panam Salud Publica. 2005;18(4-5):359-65.
• 9. Earls F, Raviola GJ, Carlson M. Promoting child and adolescent mental health in the context of the HIV/AIDS pandemic with a focus on sub-Sharan Africa. J Child Psychol Psychiatry. 2008;49(3):295-312.
• ¹⁰
  10. World Health Organization. Caring for children and adolescents with mental disorders: setting WHO directions. Geneva: World Health Organization; 2003.

What are the principles that should guide mental health policies in countries of low and middle income?

Despite the considerable advances in the care for children and adolescents with mental disorders, the ability to address the needs of the most vulnerable populations remains beyond our grasp. Many excuses are made for not mobilizing the resources needed to address the mental health needs of infants, children, and adolescents. The reality is that for a fraction of the cost of dealing with the lifelong consequences of mental disorders in children, their families and society could achieve better results with prompt attention to mental health-related problems presenting early in life. Over the lifespan, children suffering from mental disorders could achieve enhanced productivity and have a better inclusion in society, while society itself could experience a reduction in societal disruption, violence, and welfare costs. The problems and the barriers to addressing the needs do not exist solely in low- and middle-income countries, but there they are magnified by poverty, forced migration, and often intractable conflicts.

Publication Dates

• Publication in this collection
  01 Oct 2010
• Date of issue
  Sept 2010