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Advancing global child and adolescent mental health

Carolyn E. Clausen, Anthony P. S. Guerrero, Yewande O. Oshodi, Khalid Bazaid, Bennett Leventhal, Flávio Dias Silva, Muhammad Waqar Azeem, Masaru Tateno, Tjhin Wiguna, Fransiska Kaligis, Norbert Skokauskas About the authors

Mental health disorders among children and adolescents are common, with one in four facing mental health problems today. The majority of the world’s young people live in low- and middle- income countries, however there are few or no resources available to help them. Organisations and medical professionals in Norway must know that their contribution is necessary and will make a difference in advancing global child and adolescent mental health.

Mental disorders are common among children, and can be particularly difficult for the children themselves, as well as for their parents and caregivers. One in four children, either currently or at some point during their lifetime, will experience a seriously debilitating mental disorder (13). In fact, half of all lifetime cases of mental illness begin by age 14 (1, 4). Helping young children and their parents manage difficulties early in life, with preventative care and early interventions, is the best way to avoid development of these disorders (1).

Despite all of the above, in many countries medical professionals are still reluctant to speak about child and adolescent mental health problems. Some medical students find themselves shying away from psychiatry because they want to be ‘real doctors’. Child and adolescent mental disorders have no clinically implemented biological diagnostic markers, and research in many countries is carried out only by enthusiasts in their free time. Child and adolescent mental health papers are predominantly published in specialised scientific journals, while rarely published in general medical journals. In several countries child and adolescent mental health services are underfunded due to government policies that have not yet prioritised funding for the training of mental health professionals (1). No wonder that psychiatry is too often identified as the neglected ‘Cinderella’ of medicine, with child and adolescent psychiatry, in particular, synonymous with Cinderella’s even worse off and more neglected relative.

Norway, however, stands apart from other nations with investments in research, long-standing exceptional governmental policies and designated funding to address child mental health needs (5). On the global stage priorities are progressing in this same direction, but very slowly and selectively. Over the last ten years or so, child and adolescent mental health, especially some of the ‘individual’ disorders – e.g., autism spectrum disorder – have received a lot of attention, with new services and large research projects. Progress, especially in regards to the availability of services for children with autism spectrum disorder has been achieved thanks to the integration of different care providers, with contributions from committed advocates and families, supportive societal groups, and healthcare professionals (6).

The situation in low- and middle-income countries

These steps forward, however, are mainly taking place in high-income countries. In low- and middle-income countries, child psychiatry remains in a much poorer state, with a single child and adolescent psychiatrist often serving thousands of children. For example, in India, one of the most populous countries in the world, there is approximately one adolescent psychiatrist per 100,000 children (7).

Paradoxically, low- and middle-income countries are much ‘younger countries’, with the majority of the world’s children residing there. Approximately 90 % of the world’s 2.2 billion children and adolescents reside in these countries, where many are also exposed to difficult socio-economic circumstances as well as various crises and, at times, extreme suffering (1). Poverty, war, natural disasters, forced migration and resettlement, and other crises – all have a serious impact on a child’s psychological well-being (2, 811).

Even in low- and middle-income countries, with the largest populations of children, and the potential for extreme suffering, there is a clear disparity between the dire need for care and the limited, or completely unavailable, mental health services. This is despite the fact that 194 countries have committed to provide such services by ratifying the Convention on the Rights of the Child. Article 24 of this treaty, ‘Health and Health Services’, explicitly states that children have the right to good quality healthcare – the best healthcare possible. In addition, the treaty states, “…rich countries should help poorer countries achieve this” (12). With the global community’s commitment to the treaty having further established the need for collaboration in order to provide all children with their fundamental human right to holistic healthcare, we must now hold each other accountable.

In 2000, many countries committed to the Millennium Development Goals, but unfortunately not all of the goals were attained. In 2015, the United Nations expanded upon these goals, creating the Sustainable Development Goals, leading to a new recognition of the severity of the current global mental health epidemic and the need for countries to focus resources on addressing it. The United Nations elevated mental health to a high priority to be addressed by the global community, by all countries, not only those that bear the brunt of the burden (13).

While each nation is impacted by global health burdens differently, vulnerable populations and low-resource areas need the most attention from the global community. A global burden is a responsibility of all, so it is necessary to focus our efforts where they are most needed and will be most beneficial for the future of our international community as a whole.

Norway’s role

So how can Norway help to narrow the gap between the demand for care and available services in these countries with few to no viable resources? How can individual medical professionals from Norway contribute to advancing global child and adolescent mental health?

First, it is important to acknowledge that Norway is in fact already contributing significantly to the development of this field, with financial investments in global research projects and commitment to international collaborative efforts. The contributions of Norway and other donors have, however, sparked discussion about the best approach to addressing the situation and providing aid. Several prominent groups have claimed that labelling global health funding as ‘aid’ is flawed, because it assumes an inherently unequal benefactor-dependent relationship (14). The term ‘charitable giving’ usually means that the donor decides how much to give, for what purpose and to whom. Consequently, ‘aid’ is not predictable, scalable or sustainable and undermines the host country’s ‘ownership’ of – and responsibility for – health programmes (14).

Global collaboration, on the other hand, requires a collective response to shared risks and fundamental rights, where all states have mutual responsibilities. The most transformative changes in global health have come from ‘bottom-up’ social movements, such as campaigns to ban landmines or to fight HIV/AIDS (14). Through similar social movements, and the appropriate allocation of global aid, transformative changes will also come to child and adolescent mental health. Civil society has invested in the development of an agenda centred around health rights and social justice, automatically prioritising the human right to health as the key pillar for future innovative global health governance (14). Individual contributions towards the field become very important, due to their ability to build personal bridges and contribute to sustainable development for the future.

Every contribution helps: Time to take action

Individual contributions from healthcare professionals and researchers towards collaborative efforts for child and adolescent mental health can collectively bring about significant change. Norwegian senior medical doctors are entitled to a sabbatical (“overlegepermisjon”) and are free to choose how they would like to spend it. With this freedom to choose how to spend their time, why not choose to spend it on efforts towards further advancing child and adolescent mental health? If enough healthcare professionals (not only child and adolescent psychiatrists, but also paediatricians, family doctors, etc) share their individual experiences, and invest time in teaching doctors and allied professionals about child and adolescent mental health, this could create much needed rapid change.

This paper is written by a group of doctors and allied professionals, residing on five different continents, representing the World Psychiatry Association, Child and Adolescent Psychiatry Section. We would be more than happy to answer your questions and put you in touch with our colleagues around the globe, who would be grateful to have your expertise and assistance.

This article is part of the series ‘Global Health in the Era of Agenda 2030’, a collaboration between Norad, the Centre for Global Health at the University of Oslo and The Journal of the Norwegian medical association. Articles are published in English only. The views and opinions expressed in the articles are those of the authors only.

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Unicef. Fact Sheet: A summary of the rights under the convention on the rights of the child. 2015. https://www.unicef.org/crc/files/Rights_overview.pdf (18.10.2017).

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