Services may be organized round models of care which are mainly preventive or primarily therapeutic. There is no sharp distinction between the two. Determining factors will be feasibility and the availability of resources. Services may initially be organized around prevention, with therapeutic inputs developing later. Therapeutic services are themselves preventive—secondary and tertiary prevention. A detailed discussion of prevention can be found elsewhere. (13)
The importance of effective inputs for primary prevention cannot be overemphasized, particularly those deriving from basic services such as health education for young people, maternal and child health services, and education services. Effective maternal and child health services are obviously crucial for reducing the incidence of neurological deficits and abnormalities, and advances in developmental neuropsychiatry further emphasize this. It could be argued that primary prevention through maternal and child health services is already provided and need not be considered or specifically discussed in this chapter. In some countries certain specific inputs may be forgotten if a mental health focus is not introduced. For example, health education aimed at families including young people must emphasize the risk of genetically inherited anomalies in countries or cultures where consanguinous marriages are regarded as desirable. Developmental monitoring of preschool children, which facilitates the early detection of developmental delays or disabilities, may not form part of child health monitoring. In some countries focusing on preventive services may be the most cost-effective approach and lead to the greatest cost benefit.
Preventive inputs include the following.
• Community education:
reduction of culturally approved consanguinity to diminish the risk of genetically determined mental retardation; child care needs and the importance of early psychosocial stimulation;
discrimination against girls (e.g. significantly fewer girls enrolled in school or completing primary education (1)); life skills for adolescents to enhance their capacity for health-promoting behaviour and positive mental health.
• Maternal and obstetric care:
reduction of perinatal complications and brain damage.
detection and treatment of epilepsy;
early detection and community-based management of the mentally retarded;
early detection and intervention for children with sensory impairments (e.g. vision, hearing) and with delayed speech.
reduce environmental hazards such as lead poisoning.
• Child development:
early stimulation programmes for high-risk groups of parents and young children (economic and socially deprived, depressed mothers, isolated families).
• Social welfare measures—programmes for high-risk groups:
children and young people in care;
homeless, orphaned and destitute, street children, child combatants; young offenders, youngsters involved in substance misuse or prostitution.
In the following case study we describe a model of care for Sri Lanka, where resource availability and need led to the organization of services with an initial preventive focus.(14>
Case Study Sri Lanka is a developing country and therefore services had to be organized in a setting with limited resources. Needs were assessed from epidemiological data derived from international literature, clinical prevalence data, and information on risk factors obtained from research and knowledge of the prevailing risk situations in Sri Lanka. The first step was advocacy for the service to be accepted as policy, having obtained multisectoral agreement on the need for service inputs related to child mental health. The next step was to develop a service plan with priorities which were feasible within the Sri Lankan context, with rolling targets for resource development. A lack of designated resources meant that the existing service plan had to be opportunistic. Resource allocation was minimal; therefore the service was developed by maximizing the use of available resources in primary care mainly for prevention, with some promotional activities for early development. The main resources were in primary care—health workers who also made home visits to children aged under 5 years, primary school teachers (Sri Lanka has a high school enrolment and literacy rate), and understanding of cultural attitudes and family stresses. Health workers were trained to identify and work with families identified as high risk:
• neglectful or unresponsive mother
• very disorganized household
• mentally ill parent,
• intrafamilial violence
• intrafamilial alcoholism/substance misuse
• abject poverty
• family traumatized by organized violence.
Tasks were allocated according to available resources and skill levels.
It was planned to manage common non-severe problems within primary care using health workers and teachers. This strategy was triggered by the recognition of trauma as a result of the ongoing civil war. Appropriate technologies had to be identified for the specific inputs. Management of more severe complex problems has had to remain limited to tertiary centres which provided almost exclusively outpatient services, with children (with a family member) or adolescents being admitted to paediatric or adult facilities.
Aspects relevant to a therapeutic service
In this section we consider direct clinical work, liaison and consultation with health and other agencies, and data collection.
Using the grouping of disorders given above, it is possible to identify a network of required inputs which can be converted into specific service provisions. Some
examples are given below.
In conduct disorder in middle childhood where there are no risk factors in the home situation, parents require help with behaviour management. The service should be located where parents can access it most easily, which is usually the primary care setting. In a country or culture where a conduct problem will not be brought to the health service at all, it may be necessary to provide parenting advice formulated with respect to cultural values through health structures that the parents might use, such as child health services, social structures, or general educational programmes directed at parents.
In conduct disorder associated with an additional problem, such as frequent hospitalization for bronchial asthma, inputs to parents and children may also need to address anxieties about the illness and liaison with the family doctor and/or paediatrician.
Conduct disorder in a young adolescent with associated truancy and minor offending would require liaison with school, education welfare, and youth justice. The provision of formal or non-formal care may be necessary in this situation. Therapeutic help may be required and may have to be provided in a setting that the adolescent is willing to access.
Age is another important factor determining changes in the way services are provided. Adolescent services require a range of inputs from a variety of agencies. (15) The orientation of services has changed from primarily inpatient provision for the psychotic adolescent to services based more in the community, (!6) although both in-and outpatient facilities for adolescents are under-resourced in most services. Units for psychotic adolescents tend to be reluctant to admit those who may need inpatient care for other disorders. Although undesirable, admission to adult wards may be the only option for adolescents with severe obsessive-compulsive disorder. Inpatient facilities for complex problems such as an autistic adolescent with psychiatric illness or severe challenging behaviour in a young person with severe mental retardation (learning difficulties) are even more limited. Needs analyses must include these relatively rare groups so that service provision can be developed on a regional basis.
The development of community-based services is a challenge—they may need to be based in locations and to have links with agencies that adolescents will access. School- or college-based counselling, and an increase in the diagnostic skills of personnel working in community- or hospital-based general health facilities and accident and emergency departments, must form part of the service provision for adolescents.
In cultures or communities where distress is expressed through somatic symptoms, training in the recognition of mental health problems in adolescents who present with these symptoms is particularly important.
A review of the future of adolescent psychiatry (!7) noted the potential for positive mental health promotion through public health type adolescent psychiatry. Recent initiatives have included the concept of positive mental health for adolescents; for example, the WHO have developed a Life Skills initiative which has projects in a number of countries. In this review it was argued that the age range for access to child and adolescent services should be increased to 18 years to facilitate the transition to adult services, although it was recognized that the resources required may only be available in the more developed countries.
Consultation-liaison is becoming increasingly important, and should be incuded in the planning of services. Whereas the principles of liaison will form part of national or regional policy, specific links need to be developed locally and require good communication between agencies and acceptance of the value of co-operation.
The key activities in liaison are summarized below. For clinicians working in developing countries, this summary serves as a guide to what can be achieved within the services available. Paediatric liaison and liaison with adult psychiatric services are most easily organized. An offer to provide this liaison is a very useful way of raising awareness of the value of child psychiatry and gaining support for the further development of services.
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