Needs of children and adolescents

Although child psychiatry has a long history and extensive knowledge base, relatively little work has been done on estimating the needs of communities for child psychiatric services. Even more than is the case with services for adults, the provision of adequate children's services demands close integration between service systems if the needs of young people and their families are to be fully addressed. Child mental health services must be closely integrated with schools, social services, family services, juvenile justice agencies, etc.

There are fewer epidemiological surveys of the psychiatric morbidity of children and adolescents upon which needs estimates can be based. Developing methods for obtaining such data is complicated by the rapid developmental changes that take place in children and the resulting difficulty in developing standardized diagnostic methods. More so than with adults, equating need simply with diagnosis in children is a great oversimplification; knowledge about the family is essential for determining need for interventions. Nonetheless, what data exist indicate that the prevalence of psychiatric disorders in children is very high. The Center for Mental Health Services in the United States has published estimates for the states based on published epidemiological surveys. They estimate that between 5 per cent and 9 per cent of children between the ages of 5 and I9 are severely emotionally disturbed, the percentage increasing with increasing poverty in the state. Other experts, taking a broader view of the spectrum of childhood disorders, estimate that 20 to 25 per cent need treatment.(43)

In most communities, mental health service systems for children and adolescents are so poorly developed, the magnitude of unmet need is so apparent, and the resources for developing services have been so restricted, that quantitative needs estimates for planning purposes have not seemed necessary. It is also the case that there is, as yet, little consensus about what range of services is necessary or advisable, so that there is little basis for providing any coherent statement about need at a community level.

Estimating needs requires collaboration between the various systems mentioned above who have major roles in children's lives. Often the problems of children reflect the needs of their families. Because emotional problems in children most often present as behaviour problems, they often first come to the attention of schools, the police, or social agencies, and it is in that setting that needs become apparent. Because many of these problems never come to the attention of the mental health services and children's mental illnesses often go undiagnosed, utilization data from child mental health clinics, for example, will grossly underestimate the true level of need. On the other hand, schools, social service agencies, and police records may be used to provide some rough indicators. Measurable events such as juvenile arrests, children suspended or expelled from school for conduct problems, children placed in foster care, and truancy all provide information about the well being of children in the community and the need for interventions.

Meeting the mental health service needs of children and adolescents likewise requires good collaboration between the several service systems that affect children. Systems of care, bringing together these several agencies, with mechanisms for integration and co-ordination of care, are now considered state of the art. (44> The collaboration begins with the process of assessment of a child and delineation of his or her set of problems and needs. Each participant in the process provides a particular perspective, clinical, educational, or social service. Each may view the child's problem somewhat differently, so that a collaborative effort is most effective in defining the child's needs.

Because of their great importance for prevention, children's services should be accorded greater importance than they have received hitherto in most places. The provision of services for children and adolescents is discussed further in Chapter9.5.;.Z. Groups with special needs

In addition to considering the needs of individuals and populations in general, programme planners who aim to address the needs of all potential uses of mental health service systems need to make special provision for people with special needs ( ChapteLZ.!0.:.,!, Chapter Z.IG.^, and Cha.pt§L..7.:10.3). This may involve addressing problems of access in some instances. In others, it is a matter of providing special services.

Homeless people often have many unmet needs due to the wide variety of their needs and the fact that generic mental health service programmes are often not equipped to address those needs. The same characteristics that render mentally ill people vulnerable to homelessness (limited social supports, suspiciousness, distrust of mental health professionals, concurrent physical illness, or addictions) also render them difficult to engage in treatment and rehabilitation. Thus special programmes and methods have been developed to address their special needs. Outreach, case management, and flexibility in service provision are key ingredients. All major urban areas in North America and in many areas of Europe have significant numbers of homeless mentally ill people. Planners must take their needs into consideration.(45)

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