Keywords

1 Introduction

For more than 70 years there have been those arguing for more attention to the mental health of children across the globe. The rhetoric at first focused on the plight of children after the great wars of the twentieth century and as a result of the industrial revolution. In each subsequent era there has been a call for attention to the mental health of children. Most recently, with the emphasis on education, ADHD captures worldwide attention, autism is falsely seen as an epidemic and psychopharmacology as a panacea. There is without a doubt a need to address the mental health needs of children but a rational framework for understanding those needs, fitting the interventions to the diverse global cultures and ensuring sustainability of programs remains a challenge as great now or perhaps greater than at the outset of the concern with child mental health in the modern era (Kieling et al. 2011; World Health Organization 2003). The cruelest irony is that countries and regions with the largest child and adolescent populations lag significantly in the development of child and adolescent mental health policy (Belfer and Saxena 2006; Belfer 2007). Policy should not be seen to be dependent on the economic status of a country but rather on the consciousness to provide for some of its most vulnerable citizens.

There are many factors that have stymied the development of child mental health services including lack of resources both financial and professional, difficulty with access, stigma, unfounded myths about etiology, and a host of other factors (Kieling et al. 2011). Perhaps most critical has been the absence of child mental health policy (Belfer and Saxena 2006). The promulgation of policy serves to engage stakeholders, ensure accountability, garner financial resources and offers a roadmap for development. The World Health Organization in 2005 (World Health Organization 2005) and others subsequently have documented the absence of child mental health policy worldwide (Shatkin and Belfer 2004). In addition, to the lack of overall policy there has been a failure to address what should be the core values incorporated in policy (Belfer and Saxena 2006). This gap exists despite a significant contribution from the World Health Organization in the form of guidelines for policy development that not only outlined key elements of policy but discussed financing and other key aspects that would be difficult to confront in resource poor settings (World Health Organization 2005).

2 Impediments to Policy Development

Child mental health services are of necessity inter-sectorial (Harper and Cetin 2008). It is the very nature of the different sectors impacted by child mental disorders and poor child mental health that has impeded progress in policy development. Worldwide there has been competition for resources between the many sectors: adult mental health services versus child mental health services; educational services versus mental health services; disability-related services versus those focused on mental disorders. In addition, service development has often been impeded by a perceived either/or focus on prevention or services. This is clearly a false and unnecessary dichotomy.

Governments see the development of child mental health policy as opening the way to increased health expenditures and often assume that the evidence for interventions are insufficient to warrant the investment. This now runs counter to the increased evidence that effective interventions are available and that the treatment of disorders leads to less unemployment, youth suicide, and delinquent behavior (Kieling et al. 2011; Conti and Heckmann 2010; Scott et al. 2001). Non-governmental organization (NGOs), often unwittingly, let governments “off the hook” when they provide services in countries where the government fails to provide support for mental health (Belfer and Saxena 2006). The NGO services are rarely sustainable and thus when the NGO departs the populations are left unserved. Furthermore, NGOs too often operate outside the governance structures of government thus escaping regulation. When confronted with the absence of mental health policy many governments point to their ratification of the UN Convention on the Rights of the Child (Carlson 2001). While this is a significant accomplishment for many societies, the Convention is rarely fully operationalized and those provisions that would support the development of child mental health related services and interventions are neglected.

Child mental health-related policies are often found in policies associated with various segments of government serving children. For instance, policies on children who are abused and neglected are found in policies promulgated for social service agencies, policies for delinquent children are found in criminal justice policies, and a large number of child mental health related policies are found in educational policy (Krug et al. 2002; Burns et al. 1995). This fragmentation leads to an inability to focus attention on the whole child and too often is reflected in fragmented and competitive services.

It is often argued that child mental health policy cannot be developed because there is a lack of appropriate epidemiological data. However, this argument now needs to be put aside as it has been shown repeatedly that in country after country there are no epidemiological surprises when comparable, well-established methodologies are utilized (Verhulst 2004). Furthermore, solid epidemiological data has shown that over 50 % of adult mental disorders begin before the age of 14 (Kessler et al. 2010).

The World Health Organization developed a series of mental health policy and service guidelines including one for child and adolescent mental health (World Health Organization 2005). These policy and service guidelines provide virtually all the information necessary to develop mental health policy including crucial data on financing and governance.

3 Policy Behind the Curve

Too much emphasis on policy development has been on more traditional child mental health service needs. In many countries it is the desire of vested interests to see policy support through regulation, financial incentive or training increasing numbers of highly trained specialists. The emergence of “big pharma” and other interests with financial incentives have too often distorted child mental health policy (Eisenberg and Belfer 2009; Turner et al. 2008). This emphasis fails to recognize the imperative to develop more public health approaches to mental health supported by strong public policy. In populous countries, particularly low- and middle-income countries there will never be enough highly trained professionals to meet the mental health needs of the youth population. Thus, there is a need to find ways to incorporate child mental health in public health initiatives.

It is remarkable that when it has been shown that consumer advocacy can be so effective in establishing policy or highlighting a particular mental health need such as services for autistic children consumer input into policy and support for consumer involvement in policy lags in almost all countries (Bennetts et al. 2011; Funk et al. 2006).

It has been known for decades that early intervention to support children and to intervene in observable mental disorders is cost-effective. Yet, this economic data fails to be recognized. Heckman (2008) and Doyle (Doyle et al. 2009) have provided compelling financial arguments for investing in a public health approach beginning at a very early age.

4 Progress in Policy Development

Critical moments and decisions in a country’s history have sometimes led to dramatic changes in mental health policy including that related to children. The increased attention given to the plight of children after natural disasters spurs governments to create programs and policies to provide care, protection and healing (Munir et al. 2004). In China the “One Child Policy” and a concern for “left behind children” has led to an examination of existing child mental health policies (Zheng and Zheng 2015; Cheng and Sun 2015). However, it would be a mistake to consider this a problem isolated to China (Tomsa and Jenaro 2015). In almost every low income country literally many thousands of people leave behind their children to go to work in other countries and see their children infrequently (Mazzucato et al. 2015). In high-income countries and in many societies in the process of evolution the choice is to have only one or no children thus leading to the same potential consequences being addressed in China.

Turkey as a result of two devastating earthquakes and the advocacy of professional societies was able to establish a mental health law (Doyle et al. 2009). This was a significant achievement, but its implementation in regards to child mental health lags. In China, through NGO support the “iDream” program has been implemented in Chengdu to give children and adolescents a sense of “hope” for the future through facilitating access to individuals who have achieved success after adversity.Footnote 1 In Alexandria, Egypt there is a unique program of linkage that requires real estate developers to either take on the support of a public education facility or build such a facility.Footnote 2 This has resulted in the development of a model facility to serve developmentally disabled youth including the latest in diagnostic resources and helped to support a school mental health consultation program.

Brazil’s implementation of Guardianship Councils has given a voice to parents/caregivers seeking to obtain services for their children (Duarte et al. 2007). The Councils are available for all children under the age of 21 and does not emphasize an “at risk” group. These quasi-judicial bodies can resolve access to service issues. The role of the Councils is to make referrals and guarantee the delivery of service.

Chile in its efforts to improve the health and wellbeing of children has demonstrated through Chile Crece Contigo (CCC) a model for providing services to young children.Footnote 3 This is a model crosscutting initiative involving the Ministry of Social Development, Ministry of Health and Ministry of Education. While not focused on mental health its aim is to promote equal development opportunities for children ages 0–4 and prevent diseases through accessible preschool education programs, preventive health checks, parental leave and increased child support. The program now covers approximately 80 % of the 0–4 population.

China has approved a sweeping and inclusive mental health policy but it has not specific provisions for child mental health (Xiang et al. 2012a, b). As much as there is the need for independent child mental health policy undoubtedly addressing adult mental health needs child mental health will be improved to some extent. This should be recognized as well in other societies. Importantly, in China, like many other countries with a long-term planning process, the current health-related strategic plan calls for a major investment in child mental health services even in the absence of policy. China also highlights a very common global problem that is the discrepancy between access to services in rural versus urban populations (Muennig 2014). This is a phenomenon in rich and poor, well-resourced and sparsely resourced countries. How China addresses the problem may serve as a model for other countries.

The World Health Organization, through its Mental Health Gap Action Programme (mhGAP) initiative is providing models of care that can be scaled up by countries (The Lancet 2010). With evidence of the feasibility of these programs and their associated training components governments will have the evidence to promote policy development in the area of child mental health.

5 Asia: Unique Challenges and Opportunities

Asia is a diverse region but shares certain common characteristics. Professionals tend to be highly trained and very conversant with the latest findings in the scientific literature. Clinicians who work in the public sector are faced with seeing large numbers of patients thus limiting their ability to provide more psychosocial interventions. The development of allied professions has lagged with certain notable exceptions. Thus, for instance, there is the challenge to train more social workers. Focusing on policy, there is no shortage of very well-trained professionals capable of developing policy in health, mental health and other areas. In fact, some limited policies not focused on mental health have incorporated innovative, sustainable funding models. What appears to be missing is the “political will” to do more to develop child mental health policy (Richmond and Kotelchuck 1983). There are many possible reasons for this lack of “political will.” There are other pressing social problems demanding attention, a lack of understanding of how child mental health problems can be addressed, a failure to understand how addressing child mental health problems may have a positive impact on social stability, and economic achievement.

China, India, Singapore, Indonesia, Korea and other countries show evidence of active concern with child mental health and have moved to implement training and service programs that in several cases incorporate innovative ideas. South Korea pioneered an innovative form of taxation to support child mental health (World Health Organization 2003). Singapore has developed the REACH (Response, Early Assessment and intervention in Community mental Health) program, a model school consultation program, on a national level.Footnote 4

Of course the challenge is to be able to meet the needs of countries with hundreds of millions, even billions of citizens. In these instances across Asia it is evident that increased public health focused approaches will be needed along with a significant increase in the training of those in nonmedical disciplines who can work in the community in rural, underserved areas.

6 Conclusion

Developing child mental health policy should be on the public agenda in every country. All of the evidence necessary to make the argument for “stand-alone” child mental health policy has been developed. Advocacy at the highest levels of government, and the engagement with consumers to bolster advocacy and increasing awareness of child mental health needs as a part of advocacy can advance the cause of developing child mental health policy and fostering “political will” to do so (Richmond and Kotelchuck 1983).