Promotion and prevention in child mental health

INTRODUCTION The importance of psychological well-being in children and adolescent, for their healthy emotional, social, physical, cognitive and educational development, is well-recognized. There is now increasing evidence on the effectiveness of interventions to improve children's and adolescent's resilience, promote mental health and treat mental health problems and disorders. Mental health problems will contribute significantly to the global burden of disease in the 21st century, and for adolescents, mental health hurdles are already as common as some physical health problems such as asthma.1 Clinical preoccupation of the available mental health professionals of the country and the delay of these professionals to spearhead work towards promotion, prevention, identification and early intervention in child mental health has been a major lacuna. There are limited child and adolescent mental health services in India. Mostly such services are restricted to urban areas. Access to mental health services for children with a mental, emotional or behavioural disorder is substandard, not provided early enough, in sufficient supply and accessible only to a fraction of children and adolescents. We currently have tertiary care centres which attend to mental illness in hospital setting. They are therapeutic in nature and aim to treat and rehabilitate back to society. However, large gap exists in the area of prevention, mental health promotion and early intervention programmes. Child Mental Health Policy and School Mental Health Programmes have provided excellent opportunity to enhance mental health programme for children and adolescents. Focus is rightly on preschool children and school based mental health programmes which will prevent and possibly promote positive mental health. It also ensures that it will reduce behaviour disorders in children and prevent adult psychopathology. Effectiveness of child mental health intervention programmes will surely help in addressing mental health disorders among adults. Even WHO identifies the treatment gap in mental health care. World Health Organisation, asserts that many people suffering from psychiatric illnesses remain untreated, although effective treatment exists. WHO report examines the extent of this gap between the prevalence and treatment of psychiatric disorders globally. One in every 5 child has a mental health issue. If we invest in identifying the problems early and intervene at the right time, it will be more cost effective, as we will be preventing further breakdown and avoid an adult treatment and rehabilitation programme which is much more expensive. As it is rightly said that “Prevention is Better than Cure”. It is possible to prevent the majority of behaviour disorders in preschool and school environment itself. The dire need is to stimulate long-term and sustained improvement in children's health, by setting standards for high quality integrated health and social care for children from before birth, right through to adulthood. And while doing this one of the main focus area has to be the mental health and psychological wellbeing of children and young people. In order to achieve desired outcomes one should embrace all those services that contribute to the mental health care of children and adolescents, whether provided by health, education, social services or other agencies. It is also crucial to partner with services whose primary function is not mental health care, such as GPs and schools. They can always contribute by offering general advice and treatment for less severe problems, contribute towards mental health promotion, identify problems early in their development, and refer to more specialist services. This is to explicitly acknowledge that supporting children and adolescents with mental health problems is not the responsibility of specialist services alone.2 The plan should include primary mental health workers, psychologists and counselors working in GP practices, pediatric clinics, schools and youth services. They can offer consultation to families and other practitioners, outreach to identify severe or complex needs which require more specialist interventions, assessment, treatment and training where needed. We need a multi-disciplinary team or service working in a community mental health clinic or child psychiatry outpatient service, providing a specialised service for children and adolescents with more severe, complex and persistent disorders. This team can include child and adolescent psychiatrists, social workers, clinical psychologists, community psychiatric nurses, child psychotherapists, occupational therapists, art, music and drama therapists. Mental health service delivery demands effective partnerships between agencies, joint protocols to be agreed at senior officer level between the local, state and national bodies, social service organizations and educational institutions. There should be a single window operation in order to develop an effective model for child and adolescent mental health. Also services for children and adolescents should be provided irrespective of their gender, race, religion, ability, culture or sexuality. Traditionally in India, the responsibility of care and protection of children has been with families and communities. A strong knit patriarchal family that is meant to look after its children well has seldom had the realization that children are individuals with their own rights. Child and Adolescent Mental Health is the fundamental right of the children, and the approach to ensure the fulfilment of these rights so far has always been more need based rather than rights based. A typical Indian child starts his/her life in the womb with intrauterine growth retardation (30 percent) due to factors like malnutrition and anaemia. The child especially a female child continues to have deprivation and discrimination all through his/her life. Indian child undergoes multidimensional exploitation inflicted both at home and work-place; economically, sexually, personally and educationally. This results in poor identity and self-worth of the child. Even the legislative and social changes through mass movement on community awareness in the direction of compulsory schooling, have failed to ensure mental health to an Indian child. The Nation's children are a supremely important asset. Their nurture and solitude are our responsibility. Children's programmes, should find a prominent part in our national plans for the development of human resources in each sector, so that our children grow up to become responsible citizens. Equal opportunities for development to all children during the period of growth should be our aim, for this would serve our larger purpose of reducing inequality and ensuring social justice. CURRENT INDIAN SCENARIO According to the UNESCO report 2008. (U.N.D.P. REPORT 2008):3 India stands at 102nd position in the “Education for all developmental index" out of 129 countries”. 132nd place in the list of 172 nations on human development index (H.D.I) Ten percent of 5-15 year olds have a diagnosable mental health disorder. This suggests that around 50 million children under eighteen would benefit from specialist services. There are up to 20 million adolescents with a severe mental health disorder. Around 90% of children with a mental health disorder are not currently receiving any specialist service. All the elements that play key role in a child development and mental health are in unattended state in India. This includes basic amenities, poor infrastructure, and human resource development along with essential health and hygiene measures. Mental health promotion strategies need approaches that are also associated with the prevention of child and adolescent problems within communities with low Socio-economic Status (SES). Low SES can be measured in different ways including low levels of education and/or income or definitions that combine several variables. This is mainly because the factors associated with low SES are also associated with the development of violence and crime, substance abuse and child health problems. Interventions that address underlying determinants of low SES show strong efficacy in decreasing adolescent crime and violence and effectiveness in improving child health outcomes. Infact there are programs designed to improve educational pathways that show some efficacy in reducing aspects of adolescent substance use. Such interventions could also be supported in mental health promotion policy as they may assist in preventing related problems that undermine mental health. Following areas need attention for promotion, prevention, identification and intervention: Promoting Health and Well-being, Identifying Needs and Intervening Early Supporting Parenting Child, Adolescent and Family-centered Services Growing Up into Adulthood Safeguarding and Promoting the Welfare of Children and Adolescents Children and Adolescents who are Ill Children and Adolescents in Hospital Disabled Children and Adolescents and those with Complex Health Needs The Mental Health and Psychological Well-being of Children and Adolescents Medicines for Children and Adolescents Antenatal, Peri-natal and Postnatal Services ‘Primary care’ is of crucial importance and includes all first line services that have contact with children and their families. NATION'S ATTEMPT TO ADDRESS THE ISSUES The major national policies and legislations formulated in the country to ensure child rights and improvement in their status include: National Policy for Children, 1974 National Policy on Education, 1986 National Policy on Child Labour, 1987 National Nutrition Policy, 1993 National Health Policy, 2002 National Charter for Children, 2004 National Plan of Action for Children, 2005 However, there is a wide gap between identifying needs, planning, developing policies and effective implementation to bring a difference. But there is hope when concerned authorities continue to take the matter seriously and address the preliminary rights that aid in child mental health issues. “National Human Rights Commission will guard right to education and health. Focus will be on life, survival, health and basic education. Elementary education and primary health services in rural areas will get top priority.” - S. Rajendra Babu Former Chief Justice of India, Chairperson of NHRC September 2007 ACTION PLAN Prevention Effective prevention programs have been identified which may help to reduce the risk of children developing a mental problem or disorder. Some prevention programs are even more effective than later treatments, particularly in the area of conduct disorders. Significant advancements can be made when both the early years of life and the early stages of disorders are targeted.4 Mental health prevention and early intervention are relatively new fields in mental health. Progression of these initiatives involves supporting health and related staff and the community in the acquisition of the knowledge and skills needed to meet the challenges of new service directions and programs, including the provision of resources to assist implementation. Child's mental health may be affected by events such as death of a family member, marital discord or separation, environmental disasters and economic disadvantage. Children and adolescents may require interventions to ameliorate the effects of abuse or neglect, substance abuse or mental health problems or of in the early years may in delay and with practices, especially by or may to emotional or behavioural disorders. are fundamental to for children's mental health. Early and between and their is important and needs to be children, adolescents and their families who could benefit from mental health services for and treatment are not services. There are a of for a of in a to problems a of and that a problem a of and a of and a that can be can all the of Children and adolescents with single disorders rather with a of problems. A large of the available evidence not the which in clinical In services have to on from or from adult it to prevention, one attention to environmental factors and the between the that can several as some of these are of aid in and have importance in including early identification of would prevent mental and malnutrition are also and All children, adolescents and their or require to and to ensure that the child or adolescent's mental health is such as provision of education to awareness of mental health and to improve the of children's needs, and provision of for those children with needs, have a role to play in improving the for children and adolescents. in a community has a role to play in ensuring that the environment in which children are up their mental health. children with and their or the provision of education, training and need for early intervention may a in One should invest and resources in of services that will be to meet their This will include ensuring that there is a strong focus on and social in order to adolescent's into and reduce the of social so a of mental of needs may identify other of children and adolescents for service development is after children, where there has been improvement in children with conduct disorder or severe behavioural problems, children and adolescents who are adolescents in young and children, where is not that some of children with have a diagnosable mental disorder and this is even in those with severe the low level of resources available to the children and their families and a for the development of services. There is a wide in the when adolescents achieve and especially for those with and other A of is to ensure that adolescents treatment in an environment that their and to their developmental A social environment in early education and in school are related to the mental health of young The of is also mental health the are Early years School years based and needs Children in need of care Child mental health services at level should the and development and development should aim to knowledge through staff to promote mental health and and children and adolescent's mental health problems at an early should be to the developmental level and of the children and adolescent's should aim to improve the of professionals to promote and children and adolescent's mental health more by improving their knowledge and on towards mental health, more effective can take the of or and can also as a of Children in of Indian are and not and their In the family and the and in school or in work and the of social and life, children's are not much If they they are not The of is especially for a child. This children's to and to and to the of help their Child mental health is a and for any intervention to be effective there should be a between made by different to address the issues. There is a need to a that will such a may include child mental health prevention and promotion at and state levels which of urban and rural bodies, workers, practitioners, and social and responsible of among The should be to awareness on child mental health. and with of children can be a on in order to enhance knowledge and on child mental health issues. We also need and prevalence and from all the possible for and implementation. Children's need to be by All for addressing of child mental health should have children's with the opportunity for to their school should be with the of children should be in development of the child protection children should be in of schools and It is that education, training and should be part of each and every school mental health Early identification Mental health problems in children are associated with educational family and demands on social schools and the youth mental health problems not only in the children and adolescents, also for their families and into adult life and the Some children in have needs their mental health. after children are more than their to have a mental health disorder. Children and adolescents with are to more to have a mental disorder and at of young have been to have a diagnosable mental health disorder. 20 of all children and adolescents are affected by mental health problems and at of these show and social children and adolescents, problems such as child abuse and neglect, conduct and attention and are all more mental disorders are at a and they also to be increasing in Children and adolescents with mental health problems as to report more to have poor or physical health more to level at school more to and other more to TO All children and adolescent get and mental health. working in promote the mental health of all children and adolescent, early intervention and also meet the needs of children and adolescent with or complex problems. All children, adolescent and their families have to mental health care based the available evidence and provided by staff with an of skills and All children and adolescents, from to their who have mental health problems and need to have to high multi-disciplinary mental health services to ensure effective assessment, treatment and for and their families. TO THE All staff working with children has sufficient training and to promote the psychological well-being of children and their families and to identify early of of and early intervention are well a of and services and are where children and families are Children and adolescents are to mental health care when Children and adolescents with both a and a mental health disorder have to child and adolescent mental health service. are in place to ensure that specialist are of sufficient and have an training and to function of children with less mental health problems will need some In this will be provided by services in primary health care, social care, education early and the In many the intervention that a will from service. a child with behavioural problems may his/her problems are also in which an is from education. The of provision in one service may on the of other services to be working is an essential of high quality service of mental health and illness and the of the of children's emotional and behavioural Services need to be to these and ensure that staff is with the knowledge to work with the different within the community they The of those families who are or are particularly those from have been The provision of effective mental health care can be especially there are with a of such may need to be made to mental health care for the children and adolescents within these such of the is also important for This is also legislative in for provision of services and can be within to 5 This is mainly so that they are to services and for of services should also be to both child and family in order to it effective and avoid The setting in which the first contact is made may a in school which may be as less for some where is of from school for a young who The development of services for children with will require a with the and knowledge of working with children and adolescents with severe and those with or severe and their families. of with other services should be through partnerships which and enhance the quality and effectiveness of specialist provision already in working working with children and adolescents with mental health problems can be a The of of the and of the different and professionals and of their different may to poor and Effective working can improve children and adolescent's of services and to A mass of is for services to be and effective and to to a wide of demands which include the provision specialist and multi-disciplinary and treatment specialist consultation and and and consultation and work within primary care The level of will to of whether the service is in a rural or urban the of partnerships and services have they are also to offer a of specialist and this from the of a mass of services have not been to all of a which their to a Services ensure that children and adolescents treatment interventions which are by the available evidence and which take of their needs and such services are provided by and and There a that while and had important to play in the mental health needs of children and there an of planning, as as the of the and as a there a that responsible at the national and 90% one in of all adolescents with mental disorders is not receiving any This is a of several of all services to address these And also children's and mental health problems are not or and available effective treatment is not Children and adolescents with mental health problems are by the school or which are to and address mental A of treatment have been to be effective in addressing mental health problems of children and adolescents. prevention and intervention are they can require and many prevention and intervention are when to the cost mental health problems from their families and communities. programs long-term interventions and address an of factors such as family social school substance and can also be provided by work with children and where the level of need the of intervention provided in a primary care interventions should be and to the adolescent's and identified Mental health promotion and mental disorder prevention among children and adolescents need to its The needed is to from of and to health approaches based on of children, and communities. in the of child mental health is to plan and effective programs for programmes would need skills and training to it effective for both as well as A of the health approach to mental health have primary prevention of children's problems. However, education and training is for that and youth developmental and that problems in this period are to the of to mental health problems or disorders. The aim of prevention and early intervention is to be to this it is essential that a prevention is on an of health, education and social in our communities. many health, education and community this a new of mental health. The focus from clinical to a mental health and factors determinants of health and mental health such as and In professionals in mental health services be that in prevention, the social that are to health problems School and other social The country has to take care of an of its of development and India has its of the that when our children are and have to they are the human This will require to the of programs, their for and with and the of of attention is now to the need for programs to quality for that are by evidence based cost effectiveness and of implementation. We assist the implementation of and effective mental health initiatives in this relatively new in mental health services for children and adolescents India. India a in of the of its and percent of are by in of physical, social and of percent of the with percent of in rural areas. India is a state with and This of complex and country of National and a and every one of the of India is in many will need its at such a country it is to a national that all and even of all are in it may India has large in addressing like child education, health and it has failed to which is and to the child mental health. the policies and national for child mental health it that there is a wide gap between the children's needs and There is an integrated child mental health policy in India. The needs of a child are currently by different policies and different It is crucial to develop a policy to all aspects of children's mental health, than one One of such is the year which is child This plan includes Child mental health School mental health policy and Mental health policy for We need to take to of these policies where and are and in of child mental health. The of children mental health services is Even after one years of resources to meet the mental health needs of children, as well as and treatment services are is responsible for this gap in of such crucial child mental health services and the it policy and/or and/or resources and/or the of people towards the needs of We this in order to achieve positive outcomes. One is window operation for child mental health, education and will surely a in implementation of child legislations providing right results and ensuring for mental health programmes.