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 Table of Contents  
EDITORIAL
Year : 2017  |  Volume : 22  |  Issue : 2  |  Page : 80-82

Integrating mental health services delivery for children and adolescents in developing countries


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Rajesh Sagar
Room No 4088, 4th Floor, Teaching Block, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-8990.229111

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How to cite this article:
Sagar R, Hans G. Integrating mental health services delivery for children and adolescents in developing countries. J Mental Health Hum Behav 2017;22:80-2

How to cite this URL:
Sagar R, Hans G. Integrating mental health services delivery for children and adolescents in developing countries. J Mental Health Hum Behav [serial online] 2017 [cited 2018 May 20];22:80-2. Available from: http://www.jmhhb.org/text.asp?2017/22/2/80/229111



The prevalence rates for child and adolescent mental disorders are consistent worldwide at around 10%–20% without much variability in the types of the disorders.[1],[2],[3] Mental disorders are a significant contributor to the overall disease morbidity in the young population in all the societies of the world. Their impact on the overall health indicators of a nation is great given the fact that most of these disorders have a protracted and chronic course. The poor mental health of the young population has been consistently shown to be related with other adverse outcomes including poor educational achievements, substance abuse, violence, and poor reproductive health.[4] It is a matter of great concern that most mental health needs of this young population are unmet and innovation at devising a range of affordable and cost-effective interventions targeting this vulnerable population is lacking in the present research.

Children below the age of 16 years constitute over 40% of the total population in India. This is a very significant proportion of the population and constitutes considerable morbidity in a critical phase of the development. Although it has been established in several studies that psychiatric morbidity is prevalent in this subgroup of population, the development of services specifically targeted toward mental health of children in India has been very slow not keeping in pace with the growth of population. The prevalence studies which have tried to address this issue have shown a great variation in their results.[5],[6],[7],[8] The prevalence rates have been estimated to be as high as 35% in some of these studies although it may be difficult to generalize these results to the entire population. These figures are alarming and point to the fact that this issue must be addressed with highest priority given the public health impact. It is obvious that “no health is possible without mental health” and that mental health issues form an integral part of child development.[9]

The gap in the mental health services for children and adolescents is universal and is even evident in the countries with relatively better-developed health infrastructure and services.[3],[10],[11] The importance of this has been recognized by the WHO while endorsing that every country in the world should have a National Plan for Child Mental Health in 1977. The WHO's recommendations have been endorsed by The International Association for Child and Adolescent Psychiatry and the Allied Professions in 1992.[12] Guidance on how to develop a child and adolescent mental health policy in developing countries has recently become available as a part of the WHO's Mental Health Policy and Service Guidance Package.[13] The gap in the mental health services is more evident in the developing countries which have limited resources and overburdened healthcare facilities. In most of these countries, the mental health services for the children and adolescents are often delivered within the context of the adult mental health services and specialized inpatient facilities for children and adolescents are virtually nonexistent.[14] Moreover, the mental health service providers are inadequately trained to cater to the specialized needs of this population.

Despite the gains made in the reduction of the stigma against the psychiatric disorders in the recent decades, the growth of the mental health services for children and adolescents has been relatively slow. The factors responsible for this phenomenon can be categorized into ones which are common to the adult psychiatric services and the others which are unique to child and adolescent psychiatry. The common factors may include “the widespread lack of knowledge, relatively weak advocacy, lack of training, and absent financial and professional resources for program development and implementation.”[13] The factors which are more unique to the child and adolescent psychiatry are that behavioral problems of the children and adolescents are often diagnostically confusing, take more time for diagnostic clarification, and often require intersectorial and multidisciplinary approaches. Moreover, the parents who do approach the mental health facilities are often worried about the academic performance rather than the holistic development of the child. All these factors collectively produce a vast treatment gap which is further widened by stigma against behavioral abnormalities and psychiatric disorders.

Although there has been gradual improvement in the condition in last couple of decades, the areas of focus have only been what constitutes only a small fraction of overall morbidity. In India, the overall sensitization of the population and the resultant initiative as reflected in the legislation and health programs focuses on posttraumatic stress disorder, child sexual abuse, and autism; however, there is a lack of basic services for the diagnosis and treatment of common emotional, behavioral and school-related mental health problems. This patchy development and selective focus are a dangerous trend as it might take away the focus from comprehensive development of mental health services for children and adolescents in lieu of short-term achievements in these subgroups of the patient population though it in no way implies that the management of these disorders is not important.

The proposed delivery of child and adolescent services in the National Mental Health Programme of India through the District Mental Health Programme has failed to have any significant impact in improvement of the services. Although it might seem to be a rational approach keeping in view the overall shortage of mental health professionals in India, in view specialized care it would be highly desirable if the existing mental health workforce, especially psychiatrists are utilized efficiently in supervisory roles. It has been seen in the past that the persons with limited training in psychiatry have been manning the mental health services in these programs but whether it will suffice for the delivery of child and adolescent mental health services remains a matter of debate as it is generally recognized that working in this field of mental health requires more comprehensive and specialized training.

It can be stated that child and adolescent mental health services requires the development of comprehensive, highly specialized, and multidisciplinary approach because of the complex needs and requirements. The smooth running of these services will not only require the close coordination among various disciplines of medicine but also other agencies involved in children welfare either directly or indirectly including the judicial system, various governmental departments, and nongovernmental organizations. Moreover, the purview of the services cannot be limited to the diagnostic and management of the developmental and psychiatric disorders but will have to aim for educational, employment, and other rehabilitative services as well.

The importance of the close coordination between the various stakeholders as key to successful interventions cannot be underemphasized. This coordination has to be present at various levels of the service delivery from specialized tertiary care centers to primary care. The public health interventions are included in this framework and are one of the key components to the successful interventions. These interventions can range from favorable policy framework, expansion of the existing services, imparting skills at school level for early detection and intervention to drug awareness campaigns for adolescents.

Some other notable improvements in the service delivery in India have been sensitization and subsequent development of the services in other branches of medicine dealing with children and adolescents health problems. Although it has been commendable that recently a lot of focus has been given to these services like the development of guidelines on neurodevelopmental disorders by the Indian Academy of Paediatrics, attempts at unifying the services across specialties have been dismal. The need for good liaison between all the stakeholders of child and adolescent mental health services cannot be underemphasized. This issue is rather one of the fundamental bases which needs to be adequately addressed before any attempt at development of the services in this area. The key to good liaison is the better understanding of respective roles and responsibilities by each professional of the multidisciplinary teams at all the levels of service provision. In the absence of such demarcation and mutual cooperation, there are all chances that the resultant provisions will not only prove to be ineffective in the management of the target population but also result in haphazard development of the services which might be impossible to monitor, review and organize.

In conclusion, there is an urgent need to unify all the services working in the field of child and adolescent mental health at the preliminary stage of development if the desired goals of service delivery have to be met based on better understanding of respective roles and responsibilities. The unplanned and isolated service delivery models in a resource-limited setting will result in wastage of precious public funds without desired impact on mental healthcare of children and adolescents. In addition, these systems establish themselves without monitoring the subsequent integration of all stakeholders will be relatively difficult and resource exhaustive.



 
  References Top

1.
Verhulst FC. Epidemiology as a basis for the conception and planning of services. In: Remschmidt H, Belfer ML, Goodyer I, editors. Facilitating Pathways: Care, Treatment, and Prevention in Child and Adolescent Mental Health. Berlin: Springer Verlag; 2004. p. 3-15.  Back to cited text no. 1
    
2.
Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P, et al. Epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of Bangalore, India. Indian J Med Res 2005;122:67-79.  Back to cited text no. 2
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3.
Waddell C, Hua JM, Garland OM, Peters RD, McEwan K. Preventing mental disorders in children: A systematic review to inform policy-making. Can J Public Health 2007;98:166-73.  Back to cited text no. 3
    
4.
Patel V, Flisher AJ, Hetrick S, McGorry P. Mental health of young people: A global public-health challenge. Lancet 2007;369:1302-13.  Back to cited text no. 4
    
5.
Merikangas KR, Nakamura EF, Kessler RC. Epidemiology of mental disorders in children and adolescents. Dialogues Clin Neurosci 2009;11:7-20.  Back to cited text no. 5
    
6.
Nandi DN, Banerjee G, Mukherjee SP, Ghosh A, Nandi PS, Nandi S, et al. Psychiatric morbidity of a rural Indian community. Changes over a 20-year interval. Br J Psychiatry 2000;176:351-6.  Back to cited text no. 6
    
7.
Rahi M, Kumavat AP, Garg S, Singh MM. Socio-demographic co-relates of psychiatric disorders. Indian J Pediatr 2005;72:395-8.  Back to cited text no. 7
    
8.
Muzammil K, Kishore S, Semwal J. Prevalence of psychosocial problems among adolescents in district Dehradun, Uttarakhand. Indian J Public Health 2009;53:18-21.  Back to cited text no. 8
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9.
Costello EJ, Foley DL, Angold A. 10-year research update review: The epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology. J Am Acad Child Adolesc Psychiatry 2006;45:8-25.  Back to cited text no. 9
    
10.
World Health Organization. Atlas: Child and Adolescent Mental Health Resources – Global Concerns: Implications for the Future. Geneva: World Health Organization; 2005.  Back to cited text no. 10
    
11.
Belfer ML, Saxena S. WHO child atlas project. Lancet 2006;367:551-2.  Back to cited text no. 11
    
12.
Belfer ML. Critical review of world policies for mental healthcare for children and adolescents. Curr Opin Psychiatry 2007;20:349-52.  Back to cited text no. 12
    
13.
World Health Organization. Child and Adolescent Mental Health Policies and Plans: Mental Health Policy and Service Guidance Package. Geneva: World Health Organization; 2005.  Back to cited text no. 13
    
14.
Garety PA, Craig TK, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N, et al. Specialised care for early psychosis: Symptoms, social functioning and patient satisfaction: Randomised controlled trial. Br J Psychiatry 2006;188:37-45.  Back to cited text no. 14
    




 

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