The chapter considers interventions in terms of delivery platforms rather than specific disorders. This choice is because of the very high comorbidity between childhood mental and developmental disorders Bakare ; Rutter In addition, risk factors for childhood disorders are nonspecific and pluripotent. For example, children who are maltreated are at higher risk of a wide range of mental and developmental disorders Benjet, Borges, and Medina-Mora Childhood mental and developmental disorders are an emerging challenge to health care systems globally. Two contributing factors are the increases in the proportion of children and adolescents in the populations of LMICs, which is a result of reduced mortality of children under age five years Murray and others , and the fact that the onset of many adult mental and developmental disorders occurs in childhood and adolescence Kessler and others Ascertaining the global epidemiology of mental disorders is a difficult task, given the significant paucity of data for many geographical regions, as well as the cultural variations in presentation and measurement.
These issues are exacerbated when investigating mental disorders in children, particularly in LMICs where other health concerns, such as infectious diseases, are priorities. Epidemiologically, childhood mental disorders were relatively consistent across the 21 world regions defined by GBD However, these prevalence estimates were based on sparse data; some regions, such as Sub-Saharan Africa, have no data whatsoever for some disorders or no data for specific disorders in childhood. Although regional differences may exist, the lack of data makes them difficult to ascertain.
The month global prevalence of childhood mental disorders in is shown in table 8. ADHD, conduct disorder, and autism were more prevalent in males; females were more likely to suffer from anxiety disorders. Anxiety disorders and ADHD were more common in adolescents compared with children.
Most children and adolescents with mental and developmental disorders were in South Asia, reflecting the high population in this region and the reduction in mortality of infants and young children Murray and others For example, 40 percent of the population in the least developed countries is younger than age 15 years, compared with 17 percent in more developed regions United Nations Furthermore, population aging is occurring more slowly in LMICs, with some low-income countries predicted to have the youngest populations by , given their high fertility rates United Nations These trends mean that childhood mental and developmental disorders will increase in significance in LMICs.
Furthermore, the continuing reductions in infant mortality caused by infectious diseases mean more children will reach adolescence where the prevalence of mental disorders increases and the onset of adult mental disorders occurs.
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This will challenge already limited mental health services in these countries. The risk factors for childhood mental and developmental disorders shown in table 8. The health of children is highly dependent on the health and well-being of their caregivers; the environments in which the children live including home and school ; and, as they transition into adolescence, the influence of their peers.
The relative importance of a particular risk factor should be considered in terms of prevalence, strength of the association with an adverse outcome, and potential to reduce exposure to that risk factor Scott and others Using these criteria, efforts to address maternal mental health problems and improve parenting skills have the greatest potential to reduce mental and developmental disorders in children. The consequences of these disorders include the impact during childhood and the persistence of mental ill health into adult life.
In childhood, the impact is broad, encompassing the individual suffering of children, as well as the negative effects on their families and peers. This impact may include aggression toward other children and distraction of peers from learning. Children with mental and developmental disorders are at higher risk of mental and physical health problems in adulthood, as well as increased likelihood of unemployment, contact with law enforcement agencies, and need for disability support. GBD estimated burden across five time points , , , , and and found that the prevalence and burden of childhood mental disorders remained consistent between and Erskine and others Although the rates may not have changed, population growth and aging have impacts on the burden of disease attributable to mental disorders in childhood.
As the population of children increases globally, the burden of disease attributable to mental disorders in children will increase. Few countries have developed national policies and plans to address mental and developmental disorders in children. The guidelines recommend attention to a broad range of areas pertaining to childhood mental and developmental disorders box 8.
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The provision of health services for children in isolation will not prevent mental and developmental disorders or have significant benefits for children with these disorders. Instead, an ecological approach that addresses problems in the systems around children parents, family, and school in combination with targeted interventions for children is necessary to make a meaningful difference Kieling and others Financing Collaboration across sectors. Child maltreatment is a well-established risk factor for mental and developmental disorders in children Benjet, Borges, and Medina-Mora Legislation to address child maltreatment requires the support of well-integrated systems that increase public awareness and enable incident reporting to a constituted authority with investigative and interventional expertise and the ability to prosecute Svevo-Cianci, Hart, and Rubinson Limited evidence suggests that legislation to protect children living outside the family home in LMICs has benefits for their health and safety Fluke and others ; however, further research is needed to determine the effectiveness of such legislation for children living with their families of origin.
Attempts have been made to develop community- and primary care—based services in LMICs. Eickmann and others delivered a community-based psychosocial stimulation intervention to mothers in a study of infants age 12 months in four towns in Brazil. Children of mothers who received the intervention had significantly improved cognitive and motor development; the greatest effects were observed in infants whose development was mildly delayed.
The authors proposed the intervention could be delivered through local neighborhood groups run by mothers Eickmann and others Powell and others demonstrate that a psychosocial stimulation intervention could be delivered to infants in Jamaica by community health aid workers in a cluster randomized control trial of mother-infant dyads where the infants were malnourished.
The weekly home visits supporting maternal play with children showed that infants in the intervention group had improved overall development as well as improved hearing, speech, and hand-eye coordination. Health aid workers received two weeks of additional training to deliver the intervention, which was provided as part of an existing home visitation program for malnourished children Powell and others A follow-up study 25 years later found that those Jamaican children who received early psychosocial stimulation had, on average, 25 percent increased earnings, suggesting long-term economic benefits to infants receiving this intervention Gertler and others These studies show psychosocial stimulation is an effective intervention to support cognitive, language, and motor development in young children, conferring short- and long-term benefits, although mental health outcomes were not assessed.
The delivery of community-based interventions poses significant challenges, but the feasibility has been demonstrated in LMICs Bauermeister and others Brazil, the Arab Republic of Egypt, Israel, and Lebanon implemented and evaluated a comprehensive community-based program with a package of interventions that could be adapted to different countries and localities based on the following:.
Manuals were developed that enabled non-mental health professionals in areas with limited resources to deliver the interventions. The manuals consisted of education, parenting skills training, child training, and cognitive and behavioral therapy. These were adapted for local communities with attention to terminology, modifications to reduce stigma, and emphasis on culturally acceptable parenting skills. The feedback received from these sites indicates that the interventions were useful in helping children with internalizing and externalizing problems Bauermeister and others Strategies to improve access to community-based interventions require investments in gatekeepers, such as parents, teachers, and general practitioners.
Easy-to-read manuals and guides with culturally adapted strategies for the management of childhood mental disorders through nonspecialist primary care can be useful resources for practitioners seeking to develop services in such settings Eapen, Graham, and Srinath Most preventive interventions implemented in early childhood in LMICs target child development generally, rather than child mental health specifically. However, increasing evidence shows that some of these early interventions can benefit the mental health of children, with benefits maintained into adolescence and adulthood.
In Jamaica, an early stimulation program for very undernourished children, which involved home visits over two years, reduced anxiety, depression, and attention deficit disorder, and enhanced self-esteem at ages 17—18 years Walker and others In Mauritius, two years of high-quality preschool, from age three years, reduced conduct disorder and schizotypal symptoms at age 17 years and criminal offenses at age 23 years Raine and others These benefits were greatest for children who were undernourished at age three years.
Such interventions can be integrated with community-based maternal child health programs and should be prioritized in LMICs Kieling and others Schools have a profound influence on children, families, and communities. School-based mental health services also have the potential to bridge the gap between need and utilization by reaching children who would otherwise not have access to these services. These settings could provide an ideal environment in which programs for child mental health can be integrated in a cost-effective, culturally acceptable, and nonstigmatizing manner Patel, Aronson, and Divan However, the evidence for school-based interventions for childhood mental and developmental problems in LMICs is limited Kieling and others ; Maulik and Darmstadt In Jamaica, Baker-Henningham and others conducted a cluster randomized control trial of children ages 3—6 years with high levels of emotional and behavioral problems, attending 24 community preschool centers.
School attendance and parent-reported behavior at home also improved Baker-Henningham and others This study demonstrates that school-based interventions in a middle-income country are effective and feasible in reducing behavioral problems in young children.
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The long-term impacts of bullying behavior are serious; children who are victims, bullies, or both have elevated rates of psychiatric disorders in childhood and early adulthood Copeland and others Accordingly, the prevention of peer victimization in schools is an important strategy to reduce the occurrence of mental disorders and other adverse consequences in children and adults. Different approaches to reducing bullying behavior have been assessed in the literature. In one systematic review, Vreeman and Carroll grouped the interventions into three main types: curriculum interventions, whole-of-school approaches, and social and behavioral skills training.
Whole-of-school approaches have been found to be effective; these approaches use a multidisciplinary approach that includes combinations of school rules and sanctions, classroom curriculum, teacher training, individual counseling, and conflict resolution training. In a meta-analysis, Ttofi and Farrington found that school-based anti-bullying programs can reduce bullying by about 20 percent, with greater effects observed in interventions that adopt more of a whole-of-school approach. However, very few, if any, evaluations of interventions to prevent bullying have been conducted in LMICs.
Further research is required to demonstrate the effectiveness of school-based interventions supporting children with autism and intellectual disability. Agencies in the voluntary sector those that are nongovernment and not for-profit have traditionally played an important role in raising awareness of the issues faced by children with mental health difficulties and their families, as well as in reducing the associated stigma. In some countries, the voluntary sector provides the bulk of child mental health services. However, the evidence base for such interventions is poor, largely because of the absence of research support for program evaluation.
The magnitude of mental health problems affecting children and the absence of policies to guide service development are significant barriers to coordinated service provision and evaluation of voluntary sector programs for children in LMICs Omigbodun ; Patel and Thara Providing early interventions to children with developmental disorders may optimize their developmental outcomes Sonnander Screening is necessary to identify children in need of these resource-intensive interventions. Screening instruments for LMICs need to be culturally acceptable and have sound psychometric properties that have been validated in the local context Robertson and others Instruments developed for screening children for developmental disorders in HICs such as Denver II may not be appropriate Gladstone and others For example, items assessing whether a child can cut using scissors or catch a bouncing ball may be inappropriate if these resources are unavailable in the community or if parents do not model or encourage these activities.
A systematic review identified instruments that have been used for the developmental screening of young children in LMICs Robertson and others The TQ screen box 8.
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Five questions assess cognitive ability; two questions assess movement ability; one question addresses any history of seizures; one assesses vision; and one assesses hearing. The items require a dichotomous response of yes-no and ask about the skills that children will acquire in any culture. They ask parents to compare their children to other children in their community Belmont ; Zaman and others The TQ is a sensitive tool that identifies 80— percent of children with developmental disorders; however, it has a low specificity, necessitating a second stage to examine those children who screen positive Durkin and others Ten Questions Screen.
Compared with other children, did the child have any serious delay in sitting, standing, or walking? Compared with other children, does the child have difficulty seeing, either in the daytime or night? Administration of the ACCESS portfolio provides screening of children with developmental disorders, as well as simple advice to parents. Two significant issues arise following the identification of children with developmental disorders.
The first involves the stigma associated with these diagnoses in some countries and cultures. The second is the limited evidence for the effectiveness of community-based rehabilitation for children with intellectual disabilities and autism in LMICs. These issues do not necessarily indicate that interventions are ineffective, but rather that further evaluation is required Hastings, Robertson, and Yasamy ; Robertson and others Parenting skills training aims to enhance or support the parental role through education and training, thereby improving emotional and behavioral outcomes for children.
A meta-analysis identified four components of parenting skills training that were particularly effective. Several systematic reviews have demonstrated the effectiveness of parenting skills training in reducing internalizing and externalizing problems in children Furlong and others ; Kaminski and others , as well as in reducing the risk of unintentional childhood injuries Kendrick and others and improving the mental health of parents Barlow and others Childhood disruptive and externalizing behaviors may persist into adolescence, affecting peers, schools, and communities Fergusson, Horwood, and Lynskey Furthermore, although many externalizing behaviors diminish as individuals mature through adolescence, life course persistence of antisocial behaviors is more likely in those with childhood-onset conduct problems Moffitt and others A meta-analysis of group-based parenting skills training for parents of children with conduct problems showed moderate effect sizes with a standardized mean difference in conduct problems of —0.
Therefore, parenting skills interventions can reduce or prevent the onset of childhood mental disorders and subsequent adverse health and social outcomes. The evidence for the effectiveness of parenting skills training comes from studies conducted in HICs Furlong and others A systematic review of parenting interventions in LMICs reported that most studies examined educational or physical outcomes Mejia, Calam, and Sanders However, eight studies examined interventions to prevent or reduce emotional and behavioral problems in children.
The following outcomes were assessed:. Thus, emerging evidence from available research suggests parenting skills training is a feasible and effective intervention in LMICs.
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The extensive research base available from HICs requires integration with knowledge acquired from studies conducted in LMICs for the development of culturally appropriate parenting skills training. Interventions that target maternal mental health problems, especially in the perinatal period and early infancy, are important for child mental health and need to be incorporated into primary care. Perinatal mental disorders can be divided into common mental disorders including depression and anxiety disorders and severe mental disorders schizophrenia and bipolar disorder.
Two meta-analyses have reported that the prevalence of common mental disorders in women in LMICs is between Maternal depression is the most prevalent condition—and has the largest public health impact Rahman, Surkan, and others A recent systematic review identified 16 longitudinal studies of adolescent mental and developmental health outcomes of children of mothers who had postnatal depression. Increased risk of cognitive delays in the children was the most consistent finding, with some studies also reporting that children of mothers with postnatal depression had increased risk of internalizing and externalizing symptoms and increased general psychopathology Sanger and others Accordingly, treatment of maternal mental health problems can reduce suffering in the mother while potentially preventing mental and developmental disorders in the children.
Postnatal depression is the condition for which interventions are most amenable to integration into primary care and maternal and child health platforms Rahman, Surkan, and others Such integration requires task-shifting strategies, supported by the development of training curricula and treatment packages that bundle skills that are logically grouped together for content, training, and operational use Patel and others These interventions also require a change in the approach of mental health specialists, as well as health policy and planning specialists—a shift of focus from a model that is specialist and center based to a model that is primary care and community based.
Integrated treatment programs, in which health and social care providers are supported to manage common mental health problems, offer a chance to treat the whole person. This approach is more patient centered and is often more effective than one in which mental, physical, and reproductive health problems are addressed separately without effective communication among providers Patel and others Maternal and child health workers are well-positioned to adopt comprehensive approaches to care, which is particularly important for children because their psychosocial well-being is closely linked to the mental health of their parents and the quality of their family and school environments.
Maternal and child health workers have knowledge of community resources and health, social, and education services, and they can better respond to the specific needs of local communities. A cluster randomized trial demonstrated that an evidence-based program for maternal mental health and child development can be delivered through existing local health workers in an LMIC Rahman, Surkan, and others In Chile, a multicomponent intervention for postnatal depression was evaluated in a randomized control trial of women.
The intervention consisted of group education about illness and symptoms, problem-solving strategies for mothers, and structured pharmacotherapy when required, delivered through existing local primary care clinics. Compared with those who received treatment as usual, mothers with depression had significant improvements. This study demonstrates the efficacy and feasibility of delivering care to mothers with postnatal depression in an LMIC Rojas and others Improvements in maternal and infant health were achieved in a study of 19, births in rural India through monthly participatory groups facilitated by peers.
The study involved the identification of maternal and neonatal health problems, identification of solutions, and implementation and evaluation of strategies in partnership with local health services Tripathy and others Much of the research on psychological and psychosocial interventions for maternal depression has been conducted in HICs Sockol, Epperson, and Barber Over the past decade, evidence of the effectiveness of interventions led by non-mental health specialists for example, by nurses, health visitors, or midwives has increased Crockett and others ; Lumley and others ; MacArthur and others ; Morrell and others ; Roman and others In LMICs, the public health importance of maternal mental health has led to increased research on interventions.
A review and meta-analysis identified 13 trials that included 20, participants Rahman, Fisher, and others In all these studies, the intervention was delivered by supervised, nonspecialist health and community workers; in many of the studies, the intervention was integrated into a primary care platform.
Compared with routine care, the evidence suggests significant benefits for mothers and children from the interventions tested. The pooled effect size for maternal depression was 0. Where assessed, the benefits to children included improved mother-infant interaction, better cognitive development, reduced diarrheal episodes, and increased rates of immunization.
Cognitive behavioral therapy CBT is a psychological intervention used for the management of anxiety disorders in children.
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The components of CBT for children consist of cognitive interventions and behavioral strategies. The cognitive interventions teach children to recognize their anxious feelings and the somatic experiences that accompany anxiety for example, breathlessness and palpitations , identify the anxious thoughts that are associated with the anxious feelings, develop alternative thoughts for example, positive self-talk and other coping strategies, and evaluate the differences in their emotions after using the coping strategies.
The behavioral interventions include relaxation training, modeling behaviors, and graded exposure to anxiety-provoking stimuli. A meta-analysis of 41 studies examined the effectiveness of CBT compared with waitlist control, treatment as usual, and other interventions James and others Compared with waitlist controls, CBT had a large effect on reducing anxiety diagnoses and symptoms, with a standarized mean difference of —0.
In Zambia, local lay counselors delivered trauma-focused CBT to the families of 58 children and adolescents between the ages of 5 and 18 years who had moderate to severe trauma symptoms. The intervention was provided to the families of the children and achieved significant reductions in the severity of trauma symptoms, as well as the feelings of shame. In a study in Brazil, clinical psychologists delivered 14 sessions of group-based CBT, with two concurrent parental sessions, to 28 children ages 10—13 years who were suffering from anxiety disorders.
These studies provide preliminary evidence of the feasibility of CBT-based interventions for anxiety disorders in LMICs; however, further research is needed. Pharmacotherapy has the strongest evidence for reducing behavioral problems and improving the attention and educational performance of children with ADHD Benner-Davis and Heaton ; Greenhill and others ; Prasad and others The dispensing of stimulant medications is increasing in HICs Hollingworth and others ; McCarthy and others , but no studies have examined whether these trends exist in LMICs.
The wide recognition in HICs of the problems of stimulant medication diversion and misuse has resulted in recommendations for increased monitoring and regulations Kaye and Darke Therefore, although stimulant medications are very effective treatments for ADHD, the potential difficulties with obtaining comprehensive assessments of the children to ensure accurate diagnosis and the high likelihood of diversion and misuse in the absence of regulatory systems limit the feasibility of the widespread use of stimulant medications in LMICs.
Parenting interventions are the best treatments for younger children with disruptive behavioral disorders, such as oppositional defiant disorder and conduct disorder. However, the use of pharmacotherapy can assist in the treatment of adolescents with conduct disorder. Recent evidence has suggested that the use of pharmacologic agents—in particular, second-generation antipsychotics—is increasing Pringsheim and Gorman in children and adolescents with conduct disorder. Toxic stress can damage brain architecture and increase the likelihood that significant mental health problems will emerge either quickly or years later.
Because of its enduring effects on brain development and other organ systems, toxic stress can impair school readiness, academic achievement, and both physical and mental health throughout the lifespan. Circumstances associated with family stress, such as persistent poverty, may elevate the risk of serious mental health problems.
Young children who experience recurrent abuse or chronic neglect, domestic violence, or parental mental health or substance abuse problems are particularly vulnerable. Some individuals demonstrate remarkable capacities to overcome the severe challenges of early, persistent maltreatment, trauma, and emotional harm, yet there are limits to the ability of young children to recover psychologically from adversity.
Even when children have been removed from traumatizing circumstances and placed in exceptionally nurturing homes, developmental improvements are often accompanied by continuing problems in self-regulation, emotional adaptability, relating to others, and self-understanding. When children overcome these burdens, they have typically been the beneficiaries of exceptional efforts on the part of supportive adults. These findings underscore the importance of prevention and timely intervention in circumstances that put young children at serious psychological risk.
The emotional well-being of young children is directly tied to the functioning of their caregivers and the families in which they live. When these relationships are abusive, threatening, chronically neglectful, or otherwise psychologically harmful, they are a potent risk factor for the development of early mental health problems.