The current version of the mhGAP Intervention Guide has one module for child and adolescent mental and behavioral disorders [ 20 ], but additional materials are necessary. These models may be useful in other settings in order to promote collaboration and mutual education among different professionals who interact with children and families. Increasing the size of the child and adolescent mental health workforce will inevitably need other strategies, including making mental health care of children and adolescents a more attractive option for both undergraduate and postgraduate trainees, ensuring the expansion of training positions, and providing financial remuneration for child and adolescent mental health professionals that reaches levels similar to those in other areas of health care.
Training programs will increasingly need to equip the child and adolescent psychiatrist of the future with a different set of skills, including a greater awareness of rapid developments in neuroscience, psychology and the social sciences as well as the necessity of adopting a greater public health perspective and extension of the work beyond the clinic setting. As a result, CAMHS are increasingly forced to only care for the most acutely ill individuals with mental disorders and are left with few or no resources for prevention or early intervention [ 25 ]. The main challenge for CAMHS is shortage of resources including an acute shortage of child and adolescent psychiatrists [ 15 ].
As demands for services are unlikely to decrease, there will be a need for CAMHS to optimize existing resources and find innovative ways to attract more resources by reengaging with public health and primary care while also addressing stigma and other challenges. Optimizing the use of existing resources is a first step. Direct services provided by child and adolescent psychiatrists and doctoral level psychologists, are costlier than those provided by some other professionals.
Therefore, the judicious balancing of service providers to include allied professionals may create the opportunity to expand services while utilizing the same limited resources. This effort must include primary healthcare providers pediatricians, general practitioners, advanced practice nurses, and others , as well as teachers and other helping professionals.
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With proper preparation and training, allied professionals can provide some of the essential elements of care for the children, adolescents and families facing common mental disorders. Child and adolescent psychiatrists can then focus on: 1 initial diagnostic assessments; 2 care of the most complicated cases; and 3 support for allied professionals and their work.
This strategy allows for more specialists to see the more critical and complex cases and for non-specialists to be educated on how to provide treatment and when to consult with the specialist. Financing public health and prevention approaches to mental health are often been viewed as diverting resources from direct services for individuals already diagnosed with mental illnesses [ 26 ].
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Unlike preventive interventions in other medical specialties e. In other words, fostering healthy child and adolescent development, supporting parenting, and providing early and preventive interventions will reduce the burden of child and adolescent psychiatric disorders and the attendant need for CAMHS. Child and adolescent psychiatrists would ideally be active members of multidisciplinary public mental health teams and provide a biopsychosocial perspective on the prevention of mental health disorders and promotion of mental health.
For example, child and adolescent psychiatrists commonly collaborate with schools in implementing mental health literacy programs, promoting resilience and helping children and adolescents acquire the elements necessary for healthy development and, ultimately, happy and productive adult lives. CAMHS should not only reengage with public mental health, but also take an advantage of digital health interventions DHI to increase access to services.
The development of DHI has been driven by three assumptions: youth prefer digital to face-to-face intervention; DHI can greatly improve access to evidence-based therapies, which may otherwise be unavailable; and, DHI appear to be more efficient and economical than center-based care. An increasing body of evidence supports the use of computers and the internet in the provision of interventions for depression and anxiety in children and adolescents [ 27 ].
Comprehensive evaluations of the effectiveness and cost-effectiveness of multiple delivery systems to address anxiety, depression, and other disorders are needed in order to shape and disseminate new approaches to DHI. Attracting additional resources to support children and adolescents with mental disorders will require strong policy and, therefore, political support.
There are examples of effective advocacy in countries where parents insist on specialized services for children with autism spectrum disorder, increase public awareness, and place societal and political pressure on decision makers [ 28 ]. These experiences should be carefully studied, as they serve as models for attracting support for other child and adolescent mental health services. Stigma, rather than just economic considerations, may be the more persistent and pernicious cause of CAMHS resource limits. Stigma limits the allocation of resources and discourages youth and families from seeking treatment even when it is available.
Stigma is often associated with misunderstandings about psychiatric illness in youth.
It may also lead to the shortage of culturally-adapted, developmentally appropriate, evidence-based interventions [ 29 ]. Added to stigma are other barriers to access, engagement, early recognition and treatment, which are even more pronounced for vulnerable groups such as refugee children, street children, homeless families, youth in care programs, young offenders, gender non-conforming youth, victims of war and violence, and those facing social and economic disadvantage [ 30 ].
The complex needs of these youth highlight the importance of service coordination, joint care pathways, integrated psychosocial care, and embedding of psychiatric services within general medical services. The voices of these children and adolescents, as well as their parents, must be heard and must play a central role in shaping service planning, development, research, and evaluation. In the last decade, there has been a great increase in research and conceptual understandings of the effects of environment, and developmental processes on brain, behavioral, emotional, and cognitive development, as well as perturbations in such development.
Psychosocial factors that influence children with immune related health conditions
In the coming years, child and adolescent psychiatry will see substantial benefit from broad areas of research that have great promise for translating science into practice. Relevant areas include: genetics, developmental neuroscience, developmental psychology, epidemiology, phenotyping, new treatment targets, health economics and public mental health. Investment in these areas will facilitate prevention, early and more accurate diagnosis, and more effective and cost-effective treatment of mental disorders in children and adolescents. We examine a few examples bellow:.
Large, representative population and registry studies are providing accurate prevalence data, which indicate that there are significantly greater numbers of individuals affected by developmental psychopathology. However, more studies are necessary to offer insights into the breadth and variation in the phenotypes of childhood onset psychiatric disorders. These data will bring changes in our understanding of pathophysiology, diagnosis, and treatment.
Furthermore, longitudinal studies will be necessary to provide clearer pictures of normal development and its variations in the face of developmental psychopathology. With low-and middle-income countries LMICs having the highest numbers of children overall and the highest numbers of children who are exposed to adverse childhood experiences [ 1 ], there is an urgent need for a better understanding of child and adolescent mental health disorders in these countries. The most sophisticated child and adolescent psychiatry research has been conducted in high-income settings, while LMICs mental health intervention studies predominantly focus on pharmaceutical trials that often take advantage of areas with little regulation [ 31 ].
The capacity to undertake child and adolescent mental health research in LMICs is improving but remains limited [ 32 ]. In order to minimize the disparity between knowledge emanating from high-resource settings and LMICs, high income groups will have to support research in LMICs to develop better surveys, cohorts, clinical trials, and cost- effectiveness studies in child and adolescent mental health. DSM 5 and ICD 11 provide further evidence that categorical diagnosis, while robust and important, also has distinct limits [ 33 ]. The use of a categorical approach may lead to a systematic underappreciation of the importance of variations in overt symptoms and in underlying mechanisms from individual to individual.
As the field tries to more fully describe the dimensions of all aspects of developmental psychopathology, the development of new models and tools for phenotyping will be necessary. Further studies will be necessary to validate these tools and translate them for use as a part of standard clinical practice. Studies using evolving brain imaging technology e.
Further studies of the genetics including studies on coding and non-coding regions and on epigenetics and gene expression of psychopathology will be necessary to elucidate the etiologic understanding of disorders and phenotypes. Of note is growing evidence for the impact of stress and inflammatory processes on the developing brain and emergence of developmental psychopathology, both directly and through an impact on glial and other brain functions. For some time, there have been few new targets for pharmacologic interventions.
This paucity of new targets is likely to change with the growing interest in the cannabinoid, glutamate and other messaging systems in the brain. These new targets will be among those identified, as inflammatory, metabolomics and genetics studies are developed and in progress. Environmental interventions will also continue to offer opportunities for further exploration and perhaps lead to novel strategies for the mitigation of toxic exposures biological and psychological. It will be equally important to further develop evidence-based psychotherapies individual and group , as well as behavioral therapies and parent training, which are directed at specific symptoms, disorders and developmental stages.
Health economics will be essential justifying new investments in child and adolescent mental health services. It will require a broader perspective of the economic evaluation of interventions used in CAMHS and will need to account for costs and savings related to all societal sectors, including such as health, social, educational, and criminal justice services; and other impacts such as loss of productivity, family instability, and lack of self-sufficiency. Since the majority of lifetime mental illnesses develop before adulthood, effective prevention targeted at children and adolescents is likely to generate greater personal, social and economic benefits than interventions at any other time in the life course.
Prevention research can explore and provide evidence for a broad range of potential preventive strategies e. Careful planning will allow for the evaluation of safety, efficacy and cost effectiveness in standard trials. A developmental perspective should be a key underpinning of prevention research, providing insights into the pathways, continuities, and changes in normal and pathological processes over the life span [ 34 ].
It will move research away from the notion of a single causal agent and will attempt to examine different and sometimes interacting causal factors as well as identify optimal points for intervention. Given this complexity, it is expected that child and adolescent psychiatry and multiple other disciplines will work together to succeed in comprehensive preventive research trials. Development and implementation of a multi-sector policy and strategic action plans for child and adolescent mental health is a high priority.
In this process, the role of child and adolescent psychiatrists must be clearly defined. Multi-sector mental health policy is best characterized by a holistic, evidence-based approach to the identification and treatment of mental disorders, with specific attention to prevention, early intervention, and rehabilitation for psychiatric disorders [ 35 ].
To be effective, it is important that a multi-sector child and adolescent mental health policy be reflected in all levels of the government and community, and include: human rights, service organization and delivery, development of human resources, sustainable financing, civil society and advocacy, quality improvement, information systems, program evaluation and plans to address stigma.
Child and adolescent psychiatrists can and should play a greater leadership role in advocating for human rights. The United Nations Convention on the Rights of the Child is at the core of the transnational commitment to protecting children and adolescents [ 36 ]. It guarantees children the full range of human rights and sets international standards for the rights of the individual child.
Advocacy around the prevention of psychological trauma is a particularly important focus given that early childhood exposure is likely to affect formative developmental processes in a manner that impairs the foundation of future growth and that may have intergenerational consequences. Early childhood interventions including those addressing mental health and socio-emotional development should be integrated into the systems for general healthcare with adequate funding; they can and should be provided as a core element of the larger investment in the health, economic prosperity, and safety of each nation and community.
Caregiving relationships that are sensitive and responsive to infant needs are critical to human development and thereby constitute a basic right of infancy. Sound and supported parenting is a critical part of safe and effective childrearing and must be a central theme in the developmental model offered by child and adolescent psychiatry. Adolescents should be recognized as representing a special population.
On the one hand, the community must respect their developmental rights and movement toward full autonomy; on the other, there must be a recognition that their capacities may be limited in some functional areas. Adolescents therefore need a different approach in fostering healthy development and resilience. They should be protected from violence and exploitation, but approaches must take into account their emerging competencies and capacities developing during this period of life.
In many countries, mental health services for adolescents either do not exist or constitute low quality residential and in-patient services, sometimes violating human rights and relying solely on pharmacologic therapies [ 38 ]. Such services do not represent the current knowledge and acceptable standards for treatment. Although child and adolescent mental disorders are common and effective treatments are now available, services for those in need are largely unavailable. The failure to address the mental health needs of children and adolescents represents a failure to address a substantial public health problem and constitutes a profound and broad-based failure to meet intrinsic societal responsibilities.
Child and adolescent psychiatry, as a medical specialty with a strong neurobiological, psychosocial and developmental framework, is in a unique position to bring about change.
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Child and adolescent psychiatry is well-suited and well-prepared to take up the leadership role in this time of transition. This role will be enhanced by expanding the number of child and adolescent psychiatrists, as well as building a broader child and adolescent mental health workforce, an engagement with broader health service systems, a greater emphasis on preventive approaches, adapting new research into practice and taking on greater leadership in advocacy.
It will require child and adolescent psychiatrists to work differently with disciplines outside of psychiatry, including other physicians and colleagues in related mental health disciplines.
bbmpay.veritrans.co.id/navs-pagina-conocer-gente.php Together, we can work more effectively to bring social and political attention, as well as investment at local, national and global levels to assure proper care of child and adolescent mental disorders. By taking a leadership role in child and adolescent mental health and beyond, child and adolescent psychiatry will enhance healthy and productive development of our children and adolescents and the entire world community.
United Nations, D. Kessler RC, et al. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. Arch Gen Psychiatry. Global Burden of Disease Collaborative Network. Global burden of disease study GBD results seattle.