Abstract
The theme in this issue concerns the interface between child psychiatric services in low- and middle-income countries and the availability of such services in higher-income countries. In neither context are such services ideal, and resources are relatively slim when compared with demand. The key issues are discussed in three terms: first, of the need for nations to have a general statement of child and adolescent mental health policy (Shatkin et al); second, of the need to establish international child and mental health research networks to foster research in low- and middle-income countries (Erlich & Plener); and third, of the circumstances that exist for providing such support to children in one such country, Pakistan (Khan et al).
The major concern of all three sets of contributors is that there are very few countries with policies that address the mental health needs of this client group. Since the Convention on the Rights of the Child was implemented in 1989 by the United Nations, children have had, on paper at least, the opportunity to seek mental health support in all 193 countries that have ratified the agreement. There is a serious lack of resources in many of these countries. We know from international efforts to investigate the prevalence of mental health problems that they will affect up to one in five children, irrespective of culture. Shatkin et al reviewed the provision of services in all participating countries and found that only 35 had any sort of mental health policy for children, and of these only a minority provided good-quality and flexible care. In all cases, child and adolescent psychiatry was subject to the same range of policies as adult psychiatric services, however inappropriate that might be in objective terms. Clearly, the Atlas project, in which they attempted to gain an overview of child mental health provision around the world, is of potentially great value and significance, but it failed to gain adequate relevant information from many countries because there was no statutory authority tasked with collecting or providing it.
There is a need for more epidemiological information about the range and nature of child mental health problems in low- and middle-income countries, and in order to gain such knowledge we need to have more appropriate trained researchers in child psychiatry where those studies are needed. Stefan Ehrlich and Paul Plener describe how they are aiming to establish websites to assist those working in the field to conduct research, with supervision and advice ‘at a distance’. They founded the organisation Young Investigators in Biological Child and Adolescent Psychiatry, in Germany, with the aim of improving communication and collaboration between young psychiatrists starting out in this area of research. They would like to attract child and adolescent psychiatrists from low- and middle-income countries to join their network, although they acknowledge that the priorities of such psychiatrists may be very different to their own. The increasing availability of e-communication offers an exciting and novel way of promoting research in areas of the world where there are few local experts.
Finally, we consider the specific case of Pakistan, where Drs Khan, Shehzad and Chaudhry consider the difficulties in providing child psychiatry services in a country of 169 million people, of whom 40% are under the age of 15 years. There is no specific allocation of funding in Pakistan to this specialty, and no demarcated pathway by which children can be referred for assessment and intervention. Sadly, children are often admitted to adult psychiatric wards, where there is no particular medical or nursing expertise on how to manage their problems. One hope for the future may be a joint paediatric–psychiatric liaison service, but this has yet to take firm root. They emphasise the urgent need for protocols to assist in the management of children. There is also a potential role for mentoring by ‘senior volunteers’ from the Royal College of Psychiatrists, in a scheme that is attempting to bring senior professionals in the UK into dialogue with psychiatrists (such as those in Pakistan) who would value a mentor. This application of e-communication has the potential to foster the development of a special interest in managing children’s mental health among psychiatrists who have trained in adult psychiatry.