Improving Access to Care for Children With Mental Disorders
Developmental disabilities, emotional disorders and disruptive behaviour disorders are the leading mental health-related causes of the global burden of disease in children aged below 10 years. This article aims to address the treatment gap for child mental disorders through synthesising three bodies of evidence: the global evidence base on the treatment of these priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). Despite the evidence base on the burden of child mental disorders and their long-term consequences, and the recent mental health Gap Action Programme guidelines which testify to the effectiveness of a range of pharmacological and psychosocial interventions for these disorders, the vast majority of children in LMIC do not have access to these interventions. We identify three major barriers for the implementation of efficacious treatments: the lack of evidence on delivery of the treatments, the low levels of detection of child mental disorders and the shortage of skilled child mental health professionals. The evidence based on implementation, although weak, supports the use of screening measures for detection of probable disorders, coupled with a second-stage diagnostic assessment and the use of non-specialist workers in community and school settings for the delivery of psychosocial interventions. The most viable strategy to address the treatment gap is through the empowerment of existing human resources who are most intimately concerned with child care, including parents, through innovative technologies, such as mobile health, with the necessary skills for the detection and treatment of child mental disorders.
Developmental disabilities (such as intellectual disability and autism), emotional disorders (notably anxiety and depression) and disruptive behaviour disorders (notably conduct disorder and attention deficit hyperactivity disorder (ADHD)) are the leading mental health-related causes of the global burden of disease in children aged below 10 years. These disorders were also identified by global leaders in psychiatry as priorities for child mental health service development. This paper addresses improving access to care for these disorders. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). These are not only settings where the resources are scarce, but also where the probability of extreme hardships, which can enhance vulnerability to develop mental disorders, is greater. In particular, millions of children in LMIC live in circumstances of extreme poverty, low birthweight and undernutrition, high burden of communicable diseases, lack of early childhood stimulation, humanitarian crises and lack of access to education. The large resource gap for child mental disorders, arguably even larger than the widely recognised gap for adult mental disorders, is mirrored in the evidence gap. The vast majority of research on child and adolescent mental health comes from high-income countries. For example, among items on child and adolescent mental health indexed in the Web of Science database over the past decade, about 90% had an authorship from a high-income county. Authorship from upper middle-income, lower middle-income and low-income countries occurred in 7.79%, 1.19% and 0.33% of the items, respectively. This contrasts starkly with the global population of children and adolescents in the world—over 90% live in LMIC. Although this scenario is progressively changing, with proportion of authorships from leading LMIC rising (Turkey, +136%; China, +108%; and Brazil, +86%), this has to be contextualised with regard to the small current scientific output of such countries (together less than 5% of the global production). Thus, little is known about child mental disorders—their epidemiology, phenotypes, aetiology or treatment—from LMIC. With these caveats in mind, we have reviewed the available evidence to address our primary goals through three objectives: the global evidence base on the treatment of the priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care.
Abstract and Introduction
Abstract
Developmental disabilities, emotional disorders and disruptive behaviour disorders are the leading mental health-related causes of the global burden of disease in children aged below 10 years. This article aims to address the treatment gap for child mental disorders through synthesising three bodies of evidence: the global evidence base on the treatment of these priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). Despite the evidence base on the burden of child mental disorders and their long-term consequences, and the recent mental health Gap Action Programme guidelines which testify to the effectiveness of a range of pharmacological and psychosocial interventions for these disorders, the vast majority of children in LMIC do not have access to these interventions. We identify three major barriers for the implementation of efficacious treatments: the lack of evidence on delivery of the treatments, the low levels of detection of child mental disorders and the shortage of skilled child mental health professionals. The evidence based on implementation, although weak, supports the use of screening measures for detection of probable disorders, coupled with a second-stage diagnostic assessment and the use of non-specialist workers in community and school settings for the delivery of psychosocial interventions. The most viable strategy to address the treatment gap is through the empowerment of existing human resources who are most intimately concerned with child care, including parents, through innovative technologies, such as mobile health, with the necessary skills for the detection and treatment of child mental disorders.
Introduction
Developmental disabilities (such as intellectual disability and autism), emotional disorders (notably anxiety and depression) and disruptive behaviour disorders (notably conduct disorder and attention deficit hyperactivity disorder (ADHD)) are the leading mental health-related causes of the global burden of disease in children aged below 10 years. These disorders were also identified by global leaders in psychiatry as priorities for child mental health service development. This paper addresses improving access to care for these disorders. Our focus is on low-resource settings, which are mostly found in low- and middle-income countries (LMIC). These are not only settings where the resources are scarce, but also where the probability of extreme hardships, which can enhance vulnerability to develop mental disorders, is greater. In particular, millions of children in LMIC live in circumstances of extreme poverty, low birthweight and undernutrition, high burden of communicable diseases, lack of early childhood stimulation, humanitarian crises and lack of access to education. The large resource gap for child mental disorders, arguably even larger than the widely recognised gap for adult mental disorders, is mirrored in the evidence gap. The vast majority of research on child and adolescent mental health comes from high-income countries. For example, among items on child and adolescent mental health indexed in the Web of Science database over the past decade, about 90% had an authorship from a high-income county. Authorship from upper middle-income, lower middle-income and low-income countries occurred in 7.79%, 1.19% and 0.33% of the items, respectively. This contrasts starkly with the global population of children and adolescents in the world—over 90% live in LMIC. Although this scenario is progressively changing, with proportion of authorships from leading LMIC rising (Turkey, +136%; China, +108%; and Brazil, +86%), this has to be contextualised with regard to the small current scientific output of such countries (together less than 5% of the global production). Thus, little is known about child mental disorders—their epidemiology, phenotypes, aetiology or treatment—from LMIC. With these caveats in mind, we have reviewed the available evidence to address our primary goals through three objectives: the global evidence base on the treatment of the priority disorders; the barriers to implementation of this knowledge; and the innovative approaches taken to address these barriers and improve access to care.
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