On our minds: the state of child and adolescent mental health

Around the world, an estimated 166 million boys and girls aged 10 to 19 years met the criteria for a mental health disorder in 2019. That same year, suicide was among the top five causes of death among 15- to 19-year-olds in 8 of the 9 United Nations Children's Fund (UNICEF) regions, including Latin America and the Caribbean. If these facts are not necessarily new to many clinicians, researchers, and policy makers, the extra push needed to catalyze change may have finally come from UNICEF’s State of the World’s Children (SoWC) 2021 report.¹ Although published continuously since 1980, focusing on key issues that affect children worldwide, this is the first time that the SoWC has been dedicated to mental health, addressing it as a central theme for discussion and action, bringing the mental health of the world’s children into view, and thus into our minds.

Context is a key element in the contribution provided by SoWC 2021. By integrating mental health into various settings – including, but not limited to, culture, geography, income, healthcare, communities, schools, families, race, sex, digital – the report highlights the need for multidimensional and multidisciplinary initiatives and interventions to promote and maintain mental health and resolve risk factors for mental illnesses, such as unsupported parenting, deficient education, poor nutrition, poverty, discrimination, climate change, and humanitarian crises. In another essential context, the perception of young people, the preliminary results of qualitative data that UNICEF obtained¹ from focus groups of individuals aged 10 to 19 years in several countries highlight their willingness to seek mental health support, the importance of talking about mental health issues, and the need to address stigma and misunderstandings. These qualitative findings, supported by a Gallup poll performed for UNICEF as part of the Changing Childhood project,² appear in stark contrast to the scant knowledge in many countries regarding the availability and/or format of youth mental health support, as shown by a review of data from the WHO Mental Health in Development (MIND) project (https://www.mindbank.info/). Also striking is the persistent data gap, which, as pointed out a decade earlier,³ complicates the design of services and interventions.

To spark action, the SoWC 2021 describes a framework with three straightforward steps to promote, protect, and care for the mental health of children and adolescents: Commit (scale up investment), Communicate (address stigma and give voice to young people and those with lived experience of mental disorders), and Act (prepare and support parents, families, and caregivers, schools, healthcare systems and workforces, and, importantly, improve data and research).

If the scaling up of investment might raise skepticism in the COVID-19 era, the report also highlights the link between mental well-being and initiatives to minimize risk and maximize protective factors in broader areas, such as the family and school; existing programs might be strengthened by recognizing their role in protecting the mental health of children and adolescents. As one example, the report highlights cash transfer schemes (such as Bolsa Família or Auxílio Brasil) for having reduced both intimate partner violence (positively impacting cognitive and behavioral development in younger children) and suicide (with Indonesia and Brazil cited as examples). Other existing programs may also provide a unique opportunity for mental health screening, such as immunization campaigns (in which both young people and adults actively seek the healthcare system) and prenatal care (considering the well-recognized role of women in securing the mental well-being of their children).

In Brazil, much of UNICEF's Act component might profit from existing infrastructure and effective training and communication about the nature of mental health,⁴ as we propose in Box 1. This is not to say that the solution is simple: direct investment is still badly needed, among other aspects, to account for the higher cost of mental health care. Data from the cities of São Paulo and Porto Alegre show that the families of children aged 6-14 who have a mental health condition spend twice as much on health and social services as families with children who do not have one. Another a major challenge in Brazil is the difficulty transitioning into the workforce, with 27% of youth aged 18-24 years currently not in employment, education, or training (NEET),⁵ which also has a recognized link to poor mental health outcomes.

Box 1 A proposed framework for action: five fronts to secure the mental wellbeing of children and adolescents (adapted from Buchweitz et al.⁴)

1. Integrate mental and general health - Use existing opportunities for screening: prenatal care and immunization campaigns - Use existing opportunities to collect data: add relevant mental health components to population- and school-based surveys from diverse sectors - Implement relevant mental health indicators to evaluate health services in general and outline mental health-relevant treatment and care goals - Integrate mental health data into electronic health records and referral systems

2. Enhance the workforce - Review health curricula to include mental health components - Train and support primary care workers using a variety of strategies, including telemedicine - Train lay workers to provide mental health support in the community and improve access to specialized services as needed

3. Broaden research - Create evidence observatories - Foster international partnerships - Conduct high quality clinical trials for local populations, focusing on psychosocial or combined interventions

4. Strengthen participation - Mobilize media, schools, communities, and families to actively participate in initiatives to fight stigma - Disseminate information on how to access services and opportunities to contribute to policies and the legal framework - Promote collaboration among different organizations to reflect and act on shared advocacy goals - Engage youth in research and policy evaluation and planning

5. Think digital - Map available systems that can be used for mental health care - Research and develop context-sensitive digital strategies

In terms of data and research, as shown in SoWC 2021, epidemiology can guide the identification of vulnerable populations: just as knowledge on the prevalence of mental disorders is relevant for organizing services and providing care, information about risk and protective factors can support initiatives to prevent the onset and reduce the chronicity of mental health problems. In that sense, one action point to consider is including aspects of mental health in standardized worldwide surveys such as Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and the Global School-based Student Health Survey. In addition, research can connect young people to policy makers and other stakeholders to help us understand the best ways of approaching and empowering them, securing their mental wellbeing in each specific setting.

As we look ahead, it is essential to keep the entire continuum of mental health in mind, including the identification and treatment of disorders as well as the prevention and maintenance of wellbeing, thus bringing into the picture the contextual risk and protective factors that can make a difference for children and adolescents, as is already done for areas such as cardiovascular disease and cancer. There are still many uncertainties about the consequences of the COVID-19 pandemic, and the fact that a major, comprehensive report has now focused on the state of child and adolescent mental health is a positive turn that should encourage action to impact the present as well as future generations.

Acknowledgements

CK is a Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) researcher and an Academy of Medical Sciences Newton Advanced Fellow.

References

• ¹
  United Nations Children’s Fund (UNICEF). The State of the World’s Children 2021: on my mind – promoting, protecting and caring for children’s mental health [Internet]. 2021 Oct [cited 2022 Jan 4]. www.unicef.org/reports/state-worlds-children-2021
  » www.unicef.org/reports/state-worlds-children-2021
• ²
  UNICEF/Gallup. The changing childhood project. A multigenerational, international survey on 21st century childhood [Internet]. [cited 2021 Nov]. www.unicef.org/globalinsight/media/2266/file
  » www.unicef.org/globalinsight/media/2266/file
• ³
  Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, et al. Child and adolescent mental health worldwide: evidence for action. Lancet. 2011;378:1515-25.
• ⁴
  Buchweitz C, Mari J, Kieling C. Saúde mental de crianças e adolescentes no Brasil: evidências para ação. 2° Fórum de Políticas Públicas para a Infância. Eixo temático: saúde mental. São Paulo: Fundação José Luiz Egydio Setúbal; 2020.
• ⁵
  Silva ER, Vaz FM. Os jovens que não trabalham e não estudam no contexto da pandemia da covid-19 no Brasil. 2020 [cited 2021 Nov 3]. http://repositorio.ipea.gov.br/bitstream/11058/10414/1/bmt_70_jovens_que_nao.pdf
  » http://repositorio.ipea.gov.br/bitstream/11058/10414/1/bmt_70_jovens_que_nao.pdf

Publication Dates

• Publication in this collection
  14 Mar 2022
• Date of issue
  May-Jun 2022

History

• Received
  5 Nov 2021
• Accepted
  26 Dec 2021