Introduction

This chapter discusses organization of services for children and adolescents with mental health problems. It begins with a brief account of the history of service development as it relates to present-day issues. Basic principles of service organization are presented, and are illustrated by examples. Monitoring and evaluation are considered in the final section. The general principles of service provision are discussed elsewhere in this book ( Chapter.7.5, Chapter 7.6, and Chapter 7.7), and it is not our intention here to duplicate content but rather to focus on the issues arising from the clinical and organizational needs of children and adolescents.

Children with deviant behaviour have long been mentioned in the literature about the psychiatrically ill, but the history of organized services for children and adolescents began with the child guidance movement in the 1920s, first in the United States and later in the United Kingdom. This was followed by the development of outpatient and inpatient services for children and adolescents with psychiatric disorders. The aim of child guidance was to help children develop and adjust to the immediate environment, and to provide services for children and families where there were concerns about behaviour or parenting, as opposed to treating children with a psychiatric disorder. Service developments in Europe and the United States were influenced by increasing recognition and understanding of childhood disorders, initially as a result of the psychoanalytical literature, and later from the accumulating research evidence on child development and epidemiology of disorder. The development of different therapeutic strategies led to a move away from individual analytical child therapy to the use of behavioural strategies and family therapy. Subspecialities among individual disciplines developed with defined training criteria. In most countries with well-developed services for children, the multidisciplinary team became the service unit comprising a child psychiatrist, a clinical child psychologist, a child psychotherapist, psychiatric social workers, and community psychiatric nurses.

The distinction between child guidance and child psychiatry teams is no longer relevant, but attempts to differentiate between different levels of service continue. The recognition of the role of agencies other than health services in providing for child mental health has led to joint working and joint funding by health, education and social welfare services. In the United Kingdom, for example, this was an established part of service provision, although the degree to which any single agency contributed varied in different parts of the country. It was further strengthened by the recognition of high-risk groups, particularly in relation to child abuse (non-accidental injury and sexual abuse). Currently, the concept of jointly funded multidisciplinary teams has been eroded by pressures on resources in the different agencies, although the principles of joint working are strongly emphasized in government policy.

In many other parts of the world child mental health needs have not been given a high priority because of high childhood mortality and morbidity from preventable disease. This is still a very real issue for countries with a high prevalence of severe malnutrition, due at least in part to scarcity of food, and a high prevalence of infections, such as HIV and AIDS in Africa. The percentage of children reaching Grade 5 in primary school in developing countries ranges from 54 to 74 per cent. (l) Nevertheless, services have been developed in these countries, mainly in the last 30 years, owing to recognition and awareness of a need for child mental health services. They have generally followed a similar pattern of outpatient child and adolescent psychiatry services, functioning either as a separate entity or, more commonly, as part of general psychiatric services. Services are often limited because of the general lack of sufficient specialist staff in psychiatric services. They tend to be based in tertiary service settings in major cities, even in countries with predominantly rural populations. Service developments in some countries have been triggered by specific events which created an interest in particular high-risk groups. For example, help for mentally retarded children became far more developed than other aspects of child mental health when the child of the head of state was born with mental retardation (learning disability). The impact of organized violence and civil war on children has led to community-based initiatives in a number of countries where there was no previous network of child and adolescent mental health services, such as Mozambique and Nicaragua/2)

In order to raise awareness among policy-makers and planners, and to encourage systematic planning initiatives, the World Health Organization ( WHO) published a document on child mental health and psychosocial development(3) which listed the various components of child mental health services, including those for both primary and secondary prevention. The document highlighted the need for a diversity of inputs when providing for child mental health. The following guidelines to systematic planning from a country or regional point of view were suggested:

1. look at need in relation to context;

2. identify a network of services and different levels of service relevant to child and adolescent mental health;

3. develop inputs that are feasible within a particular country or community context.

As a second step in this awareness raising and planning initiative, a number of countries were invited to develop national case studies on child mental health services. Participating countries included the United Kingdom, Greece, India, Sri Lanka, Thailand, Puerto Rico, and Nigeria.

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