FORUM: MENTAL HEALTH CARE FOR CHILDREN AND ADOLESCENTS WORLDWIDE

Mental health care for children and adolescents

worldwide: a review
HELMUT REMSCHMIDT1, MYRON BELFER2
1Department of Child and Adolescent Psychiatry and Psychotherapy, Philipps-University, Hans-Sachs-Strasse 6, D-35033 Marburg, Germany
2Department of Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA 02115, USA

The magnitude of mental health problems in children and adolescents has not been recognized sufficiently by many governments and
decision-makers. This paper reviews the epidemiology of these problems as a basis for planning of services; the situation of mental health
services for children and adolescents in the various regions of the world; the principles and strategies of intervention for mental health
disorders in children and adolescents; and the role of international organizations and advocacy groups. It is concluded that old myths,
treatments and policies are no longer to be tolerated and that there is now the opportunity to develop and implement evidence-based
interventions, modern training programs and effective policies.

Key words: Children, adolescents, mental health care, systems of care, global interventions

Children and adolescents have to be has not yet been recognized sufficiently (WHO), falls in the category of “neu-
respected as human beings with clearly by many governments and decision- ropsychiatric conditions in children and
defined rights. These rights and the makers. They include not only well- adolescents”, as shown in Figure 1. This
standards that all governments should defined mental disorders, but also the estimate of the disability-adjusted life
fulfil in implementing them are fully mental health problems of children years (DALYs) actually under-represents
articulated in the United Nations (UN) exploited for labor and sex, orphaned the burden related to these disorders,
Convention on the Rights of the Child. by AIDS, or forced to migrate for eco- such as attention-deficit/hyperactivity
This Convention is universally applica- nomic and political reasons (1). These disorder (ADHD), conduct disorders,
ble to children living in all cultures and problems are increasing and are now learning disorders, mood disorders, per-
societies, and has particular relevance quantifiable. It is estimated that in 26 vasive developmental disorders and
to those living in conditions of adversi- African countries the number of chil- mental retardation (3). The WHO report
ty. Two additional documents have to dren orphaned for any reason will more “Caring for Children and Adolescents
be mentioned in connection with the than double by 2010 and 68% of these with Mental Disorders” (1) highlights
convention: the Protocol on the In- will be as a result of AIDS. 14 million that: a) worldwide, up to 20% of chil-
volvement of Children in Armed Con- children in 23 developing countries will dren and adolescents suffer from a dis-
flicts, and the Protocol on the Sale of lose one or both parents by 2010 (2). abling mental illness (4); b) worldwide,
Children, Child Prostitution, and Child A disproportionately large percentage suicide is the third leading cause of
Pornography. All these documents pro- of the “burden of disease”, as calculated death among adolescents (5); c) major
vide comprehensive guidance on the by the World Health Organization depressive disorder often has its onset in
human rights needs of children, adoles-
cents and their families.
In article 3, paragraph 3, the UN 0% 25% 50% 75% 100%
Convention on the Rights of the Child
states: “States parties ensure that the Neuropsychiatric male
conditions
institutions, services, and facilities
responsible for the care or protection of female

children shall conform with the stan-

Malignant male
dards established by competent author- neoplasms
ities, particularly in the areas of safety,
female
health, in the number and suitability of
their staff, as well as competent super- Cardiovascular male
vision”. diseases

Children with mental health prob- female

lems are entitled to profit from the guar-
antees of the Convention as stated in 0-4 years 5-9 years 10-14 years 15-19 years 20+ years

that paragraph. However, this is not the

case in many parts of the world. The Figure 1 Percentage of burden of disease in disability-adjusted life years attributable to specific
magnitude of mental health problems causes by age and sex in the year 2000 (according to the World Health Organization, 1)

147
adolescence, across diverse countries, How many children and adolescents can be used for the planning of services
and is associated with substantial psy- make use of mental health services? c) in these regions of the world. They may
chosocial impairment and risk of suicide What is the distribution of mental health not be applicable for the planning of ser-
(6); d) conduct disorders tend to persist problems and services across age, sex, vices in other parts of the world, because
into adolescence and adult life and are and ethnic groups? d) Are there histori- it is important for planners to have local-
frequently associated with delinquency, cal trends in the frequency of child and ly relevant, culture specific data.
adult crime and dissocial behavior, adolescent mental health problems? e)
marital problems, unemployment and What is the developmental course of
SYSTEMS OF CARE:
poor physical health (7). mental health problems from childhood
A GLOBAL PERSPECTIVE
The cost to society of the various into adulthood? f) What etiological fac-
mental disorders in children can now be tors can be identified to inform the design A system of care implies that there is
calculated. Leibson et al (8) reported of prevention and treatment programs? a range of services, from the least
that, over a nine-year period, the medi- g) How cost effective are child and ado- restrictive (community and family-
an medical costs for children with lescent mental health services? h) What based) to the most restrictive (hospital-
ADHD were 4,306.00 USD as com- are the outcomes for children and ado- based). The concept of a “system” does
pared with 1,944.00 USD for children lescents who received services? The not necessarily dictate a theoretical ori-
without ADHD. These data suggest answers to these questions can be used as entation or the therapies to be utilized.
that: a) mental health disorders in chil- a strong basis for planning and imple- Implementation may also lack unifor-
dren represent a huge burden for the mentation of services. mity depending on the specific setting.
children themselves, their families, and The 6-month prevalence rates of all The geographic area covered by a “sys-
society, and b) a rights framework is mental disorders in the general popula- tem” can be as small as a local commu-
necessary for children to get appropri- tion (for boys and girls together) are nity or as large as a metropolitan city or
ate, good-quality care and treatment. 16.3% in 8 year olds, 17.8% in 13 year a country. In a system, it is assumed that
olds, 16% in 18 year olds, and 18.4% in there is some form of facilitated transfer
25 year olds. If a measure of severity is of the patient between the components
EPIDEMIOLOGY AS A BASIS
taken into account, the most severe dis- of the continuum of care. Ensuring this
FOR PLANNING OF SERVICES
orders vary between 4.2% in 8 year olds facilitated flow between components of
Epidemiological data are important and 6.3% in 25 year olds (10). Table 1 a system and ensuring good communi-
for the development of public policy and gives an overview of the prevalence of cation are difficult challenges.
programs to improve mental health in mental disorders in the general popula-
children and adolescents. Epidemiologi- tion, split up into five groups, classified
Systems of care in Europe
cal research can provide answers to the according to developmental features
following questions (9): a) How many and course of illness (11,12). Systems of care in Europe are very
children and adolescents in the commu- These epidemiological data, based on much connected with the development
nity have mental health problems? b) studies in Europe and the United States, of child and adolescent psychiatry as a
medical specialty. Child and adolescent
psychiatry has its roots in the disciplines
Table 1 Prevalence of mental disorders in children and adolescents based on population
studies in Europe and the United States (from 11,12) of neurology, psychiatry, pediatrics and
psychology among others. Those work-
Early-onset disorders with lasting impairment
Mental retardation 2% Autism ~ 0.5‰
ing in the field have learned in recent
Atypical autism 1.1‰ Receptive language disorder 2-3% decades that interdisciplinary coopera-
Expressive language disorder 3-4% Dyslexia 4.5% tion is an absolute necessity for scientif-
Developmental disorders ic and clinical progress. The number of
Disorders of motor development 1.5% Nocturnal enuresis (in 9-year olds) 4.5% child psychiatrists, as well as other child
Encopresis (in 7-year olds) 1.5% Oppositional defiant disorder ~ 6.0%
mental health workers, has dramatically
Disorders of age-specific onset
increased over the last decades in nearly
Mutism (in 7-year olds) 0.8% Stuttering 1.0%
Specific phobias 3.5% Obsessive-compulsive disorder 1.0-3.5% all European countries. The situation in
Anorexia nervosa 0.5-0.8% the various countries, however, remains
Developmentally dependent interaction disorders very heterogeneous with regard not only
Feeding disorder (at age 2) 3.0% Physical abuse and neglect ~ 1.5% to the number of child psychiatrists, but
Sibling rivalry (in 8-year olds) 14.0%
also to the organization of departments
Early-onset adult-type disorders
and services, and to the research, train-
Depressive episode 2.0-4.0% Agoraphobia 0.7-2.6%
Panic disorder (in adolescents) 0.4-0.8% Somatoform disorders 0.8-1.1% ing and continuing medical education
Schizophrenia (in adolescents) 0.1-0.4% Bipolar disorder (in adolescents) <0.4% which take place within them.
Alcohol abuse (in adolescents) ~10.0% Alcohol dependence (in adolescents) 4.0-6.0% To the extent that the development
Personality disorders (in 18-year olds) ~1.0%
of services in Europe can be seen as a

148 World Psychiatry 4:3 - October 2005

Table 2 Types of mental health services for children and adolescents available in most scribe appropriately the existing systems
European countries of care in South America. The situation
Outpatient services is different from country to country.
• Child and adolescent psychiatrists in private practice There are excellent services in some
• Analytical child and adolescent psychotherapists in private practice
academic centers and newly formed pri-
• Outpatient departments at hospitals
• Child psychiatric services at public health agencies vate clinics and hospitals. Too often
• Child guidance clinics and family counselling services nearly no services exist outside urban
• Early intervention centers, social pediatric services areas. According to WHO guidelines, at
Day patient services least two child psychiatrists should
• Day patient clinics (two types: integrated into inpatient settings or independent)
• Night clinic treatment facilities
work full-time for each 60,000 children.
South America does not meet this stan-
Inpatient services
• Inpatient services at university hospitals dard but, in some cases, this is due to an
• Inpatient services at psychiatric state hospitals inadequate distribution of resources.
• Inpatient services at general community hospitals or pediatric hospitals The estimated number of child psychia-
Complementary services trists was 51 in Venezuela in 1997, and
• Rehabilitation services for special groups (e.g. children with severe head injuries, epilepsy)
85 in Chile in 2003 (15).
• Different types of residences
• Residential groups for adolescents

Systems of care in Asia

model to be emulated in other parts of government sponsored the Child and Hong et al (16) report on systems of
the world, the following conclusions Adolescent Service System Program care in China, Japan, Korea and the
can be drawn: a) the main focus of (CASSP), which was established in Philippines. Each of these countries has
service delivery is no longer on inpa- 1984 (13) and additionally supported by a special history concerning child men-
tient care, but on outpatient services, the Robert Wood Johnson Foundation’s tal health and related service develop-
day patient facilities, and complemen- Mental Health Service Program for ment, but there are some common fea-
tary services based on a community Youth (MHSPY) (14). The most suc- tures of the status and development of
level (Table 2); b) specialized services cessful of these initiatives were based on child psychiatry (mental health ser-
for certain disorders are provided with the so-called CASSP principles (13). vices) in the Asian region: a) many
highly qualified personnel and prag- According to Grimes (14), four phases countries still face serious problems of
matic, effective and efficient treatment in the development of services for men- general health and even survival; b)
programs; c) programs need to be eval- tal disorders in children and adoles- child psychiatry is a newly emerging
uated; d) the private practice of child cents can be distinguished: a) infra- subspecialty for many countries; c)
and adolescent psychiatry varies structure (the development of better most disorders classified in DSM-IV
depending on country and local cir- coordination and communication be- and ICD-10 are also found in Asian
cumstances; e) the coordination of the tween service providers and the foster- countries, but there is a need for a bet-
different services is too often insuffi- ing of an institutionalized awareness for ter understanding of cultural issues; d)
cient, which represents an obstacle for the necessity of a responsible infrastruc- the breakdown of the traditional family
the patients and affects the delivery of ture within the community); b) wrap system and the reduction in number of
effective interventions. around (the development of the means children is a focus of mental health con-
The Section of Child and Adoles- to identify needs across a set of life cern; e) working mothers’ and women’s
cent Psychiatry within the Union of domains, and the shift from a focus on equal rights movements are becoming
European Medical Specialists (UEMS) deficits to an emphasis on the child’s increasingly powerful; f) child rearing
has developed guidelines for training and families’ strengths in building inter- practices vary greatly and are some-
program development for child and ventions); c) blended funding, shared times now viewed as inappropriate;
adolescent psychiatrists. The program governance (the establishment of a con- confusing and often contradictory
has been introduced in several coun- sortium of private and public funders to advice is given by professionals on child
tries of the European Union and can support a comprehensive care program, rearing and behavioural management;
serve as a global model. The program with an adequate evaluation of efficacy g) mental health intervention methods
identifies specific requirements and and cost effectiveness); d) integrated are limited.
provides guidance on monitoring and care (the integration of mental health Only in recent years national and
quality assurance. care with all the other care systems: international child psychiatry organi-
medical, social and educational). zations have been established in the
Asian region. The Asian Society of
Systems of care in North America
Child and Adolescent Psychiatry and
Systems of care in South America
After a long period of fragmented Allied Professions (ASCAPAP) was
service development, the US federal There are no sufficient data to de- established in 1996.

149
Systems of care in Australia circumstances are found in many ent ages and developmental stages
African countries, affecting most of the need different types of intervention.
The vast size of Australia and its basic rights of children (19), such as: a) • Variability and practicability. Ide-
large non-urban population requires armed conflicts and forced recruitment ally, one should be able to adapt a
innovative service development. The of children as soldiers; b) child abuse, therapeutic technique to suit the
main problems of mental health care prostitution, and trafficking; street liv- setting in which the treatment is
for children and adolescents include ing and homelessness child labor; undertaken, e.g. outpatient or inpa-
(17): a) the inadequate funding for pub- HIV/AIDS pandemic; c) societies tient treatment, individual or group
lic mental health services; b) the resist- which do not provide for children’s treatment. The treatment approach
ance of adolescents to using mental basic needs; and d) societies which obviously needs to be practicable
health services; c) the irrational separa- allow discrimination. under the different circumstances.
tion between mental health and alco- Systems of care in Africa are either • Evaluation and assessment of
hol/substance abuse services; d) the formal or informal (18). Informal sys- effectiveness. The effectiveness of
disastrous mental health of minority tems include those provided by families an intervention needs to be proven
populations (aboriginal families); e) a and their support network, but also and compared with other interven-
lack of understanding of the needs of natural healers and faith-based organi- tions. Unfortunately, there is a
children in immigrant families; f) the zations. Formal systems are provided paucity of empirical studies con-
inadequate training of many non-psy- either by the state or the emerging pri- cerning many interventions in child
chiatric mental health staff; g) the rela- vate sector. There are no reliable data and adolescent mental health.
tively high prevalence of adolescent sui- on services in the different countries, Modern types of intervention for
cide; h) the long distance between rural except South Africa. A key problem is children and adolescents with mental
patients and urban mental health ser- the provision of education and training disorders usually comprise several
vices; i) the paucity of emergency, resi- programs in child and adolescent men- components. In planning and imple-
dential, partial hospital and in-home tal health not only for doctors and psy- mentation of treatment, it is crucial to
services; j) the poor coordination of chologists, but for all other health and select the appropriate components
services; k) the lack of funding for pre- mental health workers. and to integrate them into a coherent
ventive programs; l) the high preva- treatment plan.
lence of disruptive behavior disorders, Table 3 summarizes the intervention
PRINCIPLES AND STRATEGIES
anxiety/depression, eating disorders possibilities for the major mental disor-
OF INTERVENTION
and trauma-spectrum disorders, and m) ders seen in children and adolescents.
the need to assess the quality and effec- All interventions for mental health
tiveness of services. Important research disorders in children and adolescents
THE ROLE OF INTERNATIONAL
in the field of child mental health has should observe at least the following
ORGANIZATIONS AND CURRENT
been carried out in Australia, and effec- four principles (20):
GLOBAL INITIATIVES
tive prevention and treatment programs • Specificity. The most appropriate
have been implemented. and effective treatment technique International organizations such as
will have to be chosen for each par- the WHO, the World Psychiatric Associ-
ticular disorder. In many cases, treat- ation (WPA), the World Federation of
Systems of care in Africa
ment will comprise a combination of Mental Health, the International Associ-
Basic needs such as nutrition, water those treatment techniques most ation for Child and Adolescent Psychia-
and sanitation are the major needs in likely to be specific and effective. try and Allied Professions (IACAPAP),
Africa, where half of the population is • Age- and developmentally appro- the United Nations Educational, Scientif-
represented by children (18). Difficult priate approach. Children at differ- ic and Cultural Organization (UNESCO)

Table 3 Therapeutic interventions for priority mental disorders of children and adolescents (according to the World Health Organization, 1)
Disorder Dynamic Cognitive- Pharmaco- Family School Counselling Specialized Other
psychotherapy behavioural therapy therapy intervention interventions
therapy
Learning disorders X* X X X
ADHD X X* X
Tics X X* X
Depression (and suicidal
behaviors) X X X* X
Psychoses X* X X X
ADHD - Attention-deficit/hyperactivity disorder
*Specific treatment depends on the age of the child or adolescent

150 World Psychiatry 4:3 - October 2005

and the United Nations Children’s • The gap in meeting child mental effort comes with the recognition that
Fund (UNICEF) play an important role health training needs worldwide is there is a virtual worldwide absence of
with regard to all aspects of child and staggering, with between one half and mental health policy for children and
adolescent mental health. The predomi- two thirds of all needs going unmet in adolescents, which has hindered ser-
nant goals and activities of these organ- most countries of the world. vice development (21). The document
izations are: a) to raise the awareness • School-based consultation services is aimed toward ministers of health
for child mental health; b) to facilitate for child mental health are not regu- and other policy developers, and pro-
the establishment of appropriate servic- larly employed in both the develop- vides precise guidance on policy devel-
es in different parts of the world; c) to ing and developed world to the opment to support child and adoles-
establish training programs for all men- degree possible. This gap leads to a cent mental health services. The mod-
tal health workers in all parts of the failure to reach children who other- ule recognizes that, without policy at
world; d) to fight for the rights of chil- wise might be helped to avoid many the country level, there is little likeli-
dren and to take care that the Conven- of the problems associated with hood of priority setting, financing, and
tion on the Rights of the Child is school drop-out and other signifi- accountability.
observed in every country. Bearing in cant consequences.
mind these general principles, the fol- • Child and adolescent mental health
The WPA Presidential Global Program
lowing current global initiatives have to services funding is rarely identifiable
on Child Mental Health
be mentioned. in country budgets and in low
income countries services are often The objectives of this program,
“paid out of pocket”. supported by an unrestricted grant by
The Atlas project
• While the UN Convention on the Eli Lilly, are:
The WHO has started a series of ini- Rights of the Child is identified by • To increase the awareness of health
tiatives that should enhance the most countries as a significant docu- decision makers, health profession-
capacity of countries to develop sys- ment, rarely are the child mental als, and the general public about the
tems of care for mentally ill children health related provisions of the Con- magnitude and severity of problems
and adolescents. Prime among these vention exercised. related to mental disorders in child-
initiatives is the Atlas project. This • The work of non-governmental orga- hood and adolescence and about
project is one of the first systematic nizations in the provision of care possibilities for their resolution.
attempts to gather country-wide data rarely is connected to ongoing coun- • To promote the primary prevention
on treatment resources for children try level programs and too often lacks of mental disorders in childhood
and adolescents with mental disor- sustainability. and adolescence and foster inter-
ders. The survey, using key informants, • The development and use of “self- ventions that will contribute to the
collects data on demographic health help” or “practical help” programs, healthy mental development of
policy and legislation, mental health not dependent on trained profession- children and adolescents.
financing, mental health services, als, in developing countries appears • To offer support for the development
human resources for care, data collec- to be more a myth than a reality. of services for children and adoles-
tion capacity, care for special popula- • In 62% of the countries surveyed cents with mental disorders and
tions, and the use of medication. So there is no essential drug list for facilitate the use of effective methods
far, 64 countries have participated. child psychotropic medication. In of treatment.
The child and adolescent mental 53% of the countries there are no The program was an initiative of
health Atlas follows on Atlas projects specific controls in place for the pre- Ahmed Okasha, as President of the
for general mental health services, scription of medications. WPA, and is coordinated by an Inter-
neurological disorders, epilepsy, and • Although worldwide there is a national Steering Committee, chaired
others. The findings related to chil- great interest in ADHD, in 47% of by him. There are three task forces
dren and adolescents are striking in countries psychostimulants are within the program: the Task Force on
comparison to the data obtained for either prohibited or otherwise not Awareness, the Task Force on Primary
adult mental health services: available for use. Prevention, and the Task Force on
• In less than 1/3 of all countries it is Mental Health Services, Management
possible to identify an individual or and Treatment. The program has led to
The Child and Adolescent
governmental entity with sole several worldwide initiatives, e.g. field
Mental Health Policy Module
responsibility for child mental trials on school drop-out carried out in
health programming. The Atlas project is complemented Alexandria (Egypt), Nishnij Novgorod
• Public education about child mental by the Child and Adolescent Mental (Russia) and Porto Alegre (Brazil).
health issues lags significantly behind Health Policy Module, which is part of Results of the program have been pre-
other health related problems in all a larger mental health policy and ser- sented at the World Congress of Psy-
but the wealthiest countries. vice guidance package project. This chiatry in Cairo.

151
Advocacy for services tal health, as well as general health, is child and adolescent mental health ser-
the UN Convention on the Rights of the vices in treaties of reconciliation, as part
It is a constant challenge to develop Child. This convention is a powerful of essential guarantees at the cessation
and sustain programs to support the tool for use with governments to support of hostilities; d) the initiation of sustain-
care of children and adolescents with the development of care for children and able mental health programs for chil-
mental disorders. adolescents everywhere in the world. dren and adolescents.
Advocacy seeks to keep the needs of Other important documents and con-
these populations on the agenda of ventions of great importance are: a) the
CONCLUSION
nations and communities. Parental Declaration of Helsinki (1984), revised
advocacy has been a force for the devel- in Tokyo (1995) and in Edinburgh Child and adolescent psychiatry and
opment and maintenance of programs. (2000), codifying the ethical principles child and adolescent mental health
Professional organizations of all types of research in medicine; b) the Bioethics services have evolved in remarkable
have also advocated for care, but often Convention of the European Union; c) ways in the past few decades. Old
in a manner serving the particular needs the Belmont Report proposed by the US myths, old treatments and old policies
of their profession. It should be the aim National Commission for the Protection are no longer to be tolerated. In this
of all international organizations devot- of Human Subjects in Biomedical and new era there is the opportunity to
ed to mental health of children to facili- Behavioral Research (1978); d) the Dec- develop and implement evidence-
tate broader advocacy efforts every- laration of Madrid of the WPA (2002), based interventions, modern training
where in the world. containing the ethical principles of programs and effective policies. Advo-
Advocacy for child and adolescent research with human beings. cacy for these initiatives is the responsi-
mental health should not be the sole The IACAPAP is an umbrella for bility of many. The reward will be to see
domain of mental health profession- child and adolescent mental health a healthier and happier population of
als or those impacted by mental disor- organizations throughout the world children and adolescents and more
ders and their families. The health, and has paid special attention to the productive and stable societies.
social service, juvenile justice and promotion of the rights of children.
education sectors also have key roles Ethical issues have always been a major References
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