Leading article
Child and adolescent mental health care
A priority for Sri Lanka, and we may have to start from scratch
Ceylon Medical Journal, 2000; 45:100-102

Although Sri Lanka can be justifiably proud of some of its national health indicators, such as the relatively low infant mortality rate, efficient immunisation program, and the extensive primary health care services, when it comes to total health care in children and adolescents there is much room for improvement. Total health must take into account their physical, psycosocial needs, and help them to reach the full development through promotion of health, disability and treatment of illness. To what extent do the health  services in Sri Lanka provide for mental health needs of children and adolescents? The answer is obvious almost nothing. Absence of a clear national policy for child and adolescent mental health service and lack of comprehension by the authorities of the need for one, resulting in inadequate allocation of resources, have contributed to this dismal state. With increased public demand for such services, the discrepancy between the health care infrastructure and the mental health needs of children has widened in the last two decades, but there is little hope of increased funding.

Current situation
A large number of children and adolescents in Sri Lanka suffer from poverty and disabilities, are refugees, are exposed to the trauma of war, live on the streets, or are abused in their own homes or outside. All these are highly adverse to the mental health of children, their families and the community, because of the emotional distress involved, and the disruption to their personal and social functioning. Reliable statistics on mental health morbidity of people under the age of 18 years in Sri Lanka are not available. Prevalence of child mental disease in developing countries generally is about 29% (1). 42% of our population is under the age of 18 years, and so, a large number of chil­dren and adolescents are likely to be suffering from mental health problems. To make matters worse, lack of effective networking between health, education, social services and probation and childcare, prevent these services working in a coordinated way. As a result, even the limited resources available that could benefit the mental health of children are wasted.

Need for mental health care
Children and adolescents are a critical resource for the future of a nation. To be intellectually and emotionally prepared for the technological and social challenges of the modem world they have to be healthy. Mental health problem hamper their intellectual, emotional and social development. Longitudinal studies show that about half the children with emotional and behavioural disorders show the same disorders years later and in adulthood (2). 60% of children identified by mothers to have problem behaviours at 3 years of age were confirmed as such by teachers at 8 years (3). Hyperactivity, impulsiveness and early conduct predict greater likelihood of criminal activity as adults (4).

Burden of suffering
Burden of suffering (5) is a concept that attempts to estimate the impact of health related conditions on a society, as measured by frequency of occurrence, mor­bidity and cost, both financial and human. Childhood and adolescent mental health problems rate high in all three measures (5). Developmental disorders and disruptive behaviour disorders results in the largest aggregate burden of suffering (6). Thus, the concept is useful in identifying, prioritising and implementing useful strategies in health care provision.

Models of care
Mental health care implies two aspects of implementation and action; diagnosis and treatment of established mental health disorders and distress, and prevention. Mental problems in children and adolescents can be prevented by early identification and intervention, and also roving their resilience. Knowledge of risk and protective factors relevant to mental health in this group is useful in preventive interventions. Behavioural and emotional disorders in many children can be prevented, or treated at an earlier stage (7). A causal chain of events unresponsive parenting leading to poor language development, learning difficulties in school and behaviour problems, are preventable by better parenting and early intellectual stimulation of children (8).

Prevention
Focus on preventive mental health care is relevant to Sri Lanka as trained mental health professionals with the expertise to manage mental disorders in children are a scarce commodity, with no likelihood of increase for many years to come. National programs on prevention need collaborative partnership between many agencies taking a proactive, multilevel, systemic approach. Health services have the primary responsibility in planning, co-ordinating and 

and monitoring such programs. Schools, statutory and voluntary organisations involved in social welfare, community groups and parents, can provide an importantcomplementary support to health professionals.

Risk factors
Risk factors increase the likelihood of a child developing an emotional or behavioural disorder (9). Impact of the risk is determined by the quality of environment, in a situation faced (10). Risk for child's coping skills and the addition to seriousness of the mental health problems is increased in children with learning disability, chronic and recurrent physical illness, brain disorders, difficult temperament, economic disadvantage, mentally ill parents, institutional upbringing and families having a high level of conflict and dysfunction (11). For instance, children from alcoholic families are at risk of learning disability, school failure, emotional problems, and later, criminality and alcoholism (12). 40% of children of parents who suffer from depressive illness are at risk of suffering from major depression (13). 72.8% of children with war related experiences suffer from post-traumatic stress disorder, somatising symptoms and other psychological disturbances (14,15).

Protective factors
Certain characteristics in children and adolescents and their environments, such as good academic skills, close friendships, participation in social group activities and availability of confiding adult support, make them resilient to adverse life events (16). Well functioning parents who help their children with adjustment are also protective in adverse circumstances (13,16,17). Mental health promotion programs for children and adolescents ought to focus on enabling and facilitating problem-solving skills, self-esteem, secure attachments, and on improving the competence of parents (7).

Preventive care
Primary health care (PHC) physicians and paediatricians indirectly play a crucial role in preventative mental health care through their contribution to physical health, growth and nutrition. However, they discuss behaviour and emotional problems in children with chronic illness less often (18). Doctors should be trained to recognise psychosocial complications of chronic and recurrent illness, so that they can help children cope with ill health, and educate and inform families. PHC is an ideal setting for early identification and intervention in mental health problems, and a range or strategies can be used to achieve this. Training of PHC physicians and support health staff should include practical aspects of mental health care, with provision of incentives for development of such skills. Availability checklists would facilitate problems, early signs of maladaptive behaviours, child abuse, family dysfunction and depression in mothers. Training and supervision of of disabled children and providing supportive counselling would help to reduce the enormous burden that such families experience. A study has shown that advice and guidance on managing children with developmental and behavioural problems was valued by them(19). School  health teams too can play a definitive role in early identification of learning difficulties and hyperactivity in children, and in sensitising teachers to understand and help such children. Established preventive programs used successfully in other countries modified to suit local culture, may provide useful processes and strategies for implementation in Sri Lanka.

References
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18. Britto MT, Garrent TM, Dugliss MA, Johnson CA, Majure TM, Leigh MW. Preventive services received by adolescent with cystic fibrosis and sickle cell disease. Archives of Pediatric and Adolescent Medicine 1999; 153: 27-32.
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Hemamali Perera, Senior Lecturer in Psychological Medicine, Faculty of Medicine, University of Colombo.