Myron L. Belfer

Child and adolescent mental health worldwide: evidence for action

Mental health problems affect 10-20% of children and adolescents worldwide. Despite their relevance as a leading cause of health-related disability in this age group and their longlasting effects throughout life, the mental health needs of children and adolescents are neglected, especially in low-income and middle-income countries. In this report we review the evidence and the gaps in the published work in terms of prevalence, risk and protective factors, and interventions to prevent and treat childhood and adolescent mental health problems. We also discuss barriers to, and approaches for, the implementation of such strategies in low-resource settings. Action is imperative to reduce the burden of mental health problems in future generations and to allow for the full development of vulnerable children and adolescents worldwide.

Completed suicide and psychiatric diagnoses in young people: a critical examination of the evidence.

Suicide rates of young people are increasing in many geographic areas. There is a need to recognize more precisely the role of specific mental disorders and their comparative importance for understanding suicide and its prevention. The authors reviewed the published English-language research, where psychiatric diagnoses that met diagnostic criteria were reported, to reexamine the presence and distribution of mental disorders in cases of completed suicide among young people worldwide. The number and geographical distribution of cases were limited (N = 894 cases). The majority of cases (88.6%) had a diagnosis of at least 1 mental disorder. Mood disorders were most frequent (42.1%), followed by substance-related disorders (40.8%) and disruptive behavior disorders (20.8%). Those strategies focusing exclusively on the prevention and treatment of depression in young people need to be reconsidered. A comprehensive suicide prevention strategy among young people should target mental disorders as a whole, not depression alone, and consider contextual factors.

Twenty year experience in maxillocraniofacial surgery. An evaluation of early surgery on growth, function and body image.

We have analyzed 404 patients with a wide variety of maxillary and craniofacial deformities. These do not include head and neck cancer patients as generally defined. Satisfaction has been high as judged by the patients, surgeons and psychiatrists. The complication rate has been significant, approximately 30%, the most common being infection or loss of bone grafts. As experience accumulated, the concept of earlier operative intervention has emerged as an aid in unlocking growth potential, diminishing secondary deformity and improving the development of body image.

Treated prevalence of and mental health services received by children and adolescents in 42 low‐and‐middle‐income countries

BACKGROUND Little is known about the treated prevalence and services received by children and adolescents in low- and middle-income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs. METHODS The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), a 155-indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower-middle, and 5 upper-middle-income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO-AIMS instrument. RESULTS The median one-year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health. CONCLUSIONS Mental health services for children and adolescents in low- and middle-income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.

AIDS in children and adolescents.

Abstract AIDS in children and adolescents is a significant medical illness with increasing impact on the psychological lives of infected and noninfected individuals. AIDS has impacted on the neuropsychological, psychological, and social functioning of children. The illness is imbedded in ongoing issues for the psychiatric care of children and adolescents. An understanding of the impact of AIDS for psychological development and the necessity of specialized support services for providers is discussed.

Child and adolescent mental health in Latin America and the Caribbean: problems, progress, and policy research

La situacion de la salud mental de los ninos y adolescentes en America Latina y el Caribe es muy desigual, como lo son la composicion etnica, los avances macroeconomicos, la estabilidad y las estructuras politicas, la organizacion social, la forma de control gubernamental sobre los servicios de salud mental, el grado de urbanizacion y la turbulencia politica y social en los diversos paises. Los recursos destinados a las investigaciones y servicios clinicos varian tambien de un pais a otro. Muchos de los paises latinoamericanos y caribenos cuentan con programas innovadores de salud mental, pero falta coordinacion en la planificacion y la asignacion de los recursos. En el presente articulo se identifican los aspectos clave relacionados con el deficit en la capacidad de estos servicios en America Latina y el Caribe. Se exponen las nuevas iniciativas dirigidas a mejorar el acceso a los servicios y a mejorar su calidad sobre la base de proteger los derechos de los pacientes, entre ellas algunos novedosos programas preventivos. Ademas, se describe el enfasis creciente en las investigaciones relacionadas con las politicas.

Critical review of world policies for mental healthcare for children and adolescents.

Purpose of review Policy development is essential for the development of child and adolescent mental health services. The gaps in policy and knowledge on how to develop policy have hindered the development of sustainable services. Recent findings The WHO has now objectively identified gaps in child and adolescent mental health policy and services worldwide through its Atlas project. Others have identified the need to use evidence-based interventions in developing services and the need for ongoing evaluation. These latter elements are essential for effective policy implementation. Summary Data are now available worldwide to move forward with advocacy for child and adolescent mental health policy development.

Caring for children and adolescents in the aftermath of natural disasters

The recent Southeast Asia tsunami confronted countries with the challenge to provide mental healthcare to children and adolescents who experienced loss, displacement and disruption of daily lives. The region that was affected is resource poor, however a great deal could be learned about the needed approaches to care, and the cautions that had to be exercised to avoid doing harm. The experience highlights the need to enhance the capacities for appropriate needs assessment, diagnosis, triage and post-disaster support in terms of schooling and employment.

Substance Abuse and Violence: Cause and Consequence.

Substance abuse has been associated with violent behavior for many decades. While the relationship is the same today as it was in the past, the pervasiveness of the association, and the consequences, are more dramatic. There are two ways in which substance abuse is related to violence. First, violence can be and is perpetrated under the influence of substances, and second, violence related to substance abuse stems from the trade in drugs, which is all too often focused in poor and underserved communities. The elimination of the market for drugs, and thus the reduction in the demand for drugs, will bring about a reduction in substance abuse-related violence.

Effects of a child with a craniofacial anomaly on stability of the parental relationship.

The purpose of this study was to determine rates of divorce in parents of children with various types of craniofacial anomalies and to analyze possible confounding factors.A 29-question survey was sent to parents of all children evaluated in the Craniofacial Centre between 1992 and 1997. Parents were questioned regarding pre- and postnatal marital stability, whether the childs facial anomaly contributed to divorce, and involvement in the childs welfare. Using deformational posterior plagiocephaly as a control group, rates of divorce vs. non-divorce were compared for craniofacial anomalies, categorized as asymmetric (hemifacial microsomia, unilateral coronal synostosis, cleft lip, cleft lip/palate) or symmetric (syndromic-craniosynostosis, orbital hypertelorism, Treacher Collins syndrome). Major anomalies (hemifacial microsomia, craniosynostosis, orbital hypertelorism, Treacher Collins syndrome) were also compared to minor anomalies (cleft lip, cleft lip/palate).Surveys were sent to both parents in 412 families; 403 surveys were returned; and the results were evaluated in 275 families (67%). Frequency analysis demonstrated an overall divorce rate of 6.8% and 4.9% separation. Anomalies associated with the highest rate of divorce were hemifacial microsomia (24.0%), syndromic craniosynostosis (12.2%), and cleft lip/palate (6.8%). 79% of non-divorced couples reported a strong prenatal relationship, whereas 59% of divorced couples reported a problematic relationship. Following birth of the affected child, 47% of non-divorced couples responded that the bonds became stronger and 41% of divorced couples thought the relationship worsened. Two-sided Fisher exact test comparing control vs. all other anomalies showed significance (p=.030) for rates of divorce. Separation of anomalies into asymmetric vs. symmetric and major vs. minor categories demonstrated no significant difference in divorce rate (p> .05). The mother was more likely to become a childs primary caregiver following estrangement.