Setting the global agenda for social psychiatry: child and adolescent psychiatric perspectives

Rama Rao Gogineni; Eugenio M Rothe; Andres J Pumariega

doi:10.4103/WSP.WSP_12_19

PERSPECTIVE/VIEWPOINT

Year : 2019 | Volume : 1 | Issue : 1 | Page : 53-61

Setting the global agenda for social psychiatry: child and adolescent psychiatric perspectives

Rama Rao Gogineni¹, Eugenio M Rothe², Andres J Pumariega³
¹ Department of Psychiatry, Cooper Medical School of Rowan University, Camden, New Jersey, USA
² Department of Psychiatry and Public Health, Herbert Wertheim College of Medicine, International University, Miami, Florida, USA
³ Department of Psychiatry, University of Florida College of Medicine, Gainesville, Florida, USA

Date of Submission	16-Jun-2019
Date of Decision	09-Jul-2019
Date of Acceptance	09-Jul-2019
Date of Web Publication	27-Sep-2019

Correspondence Address:
Prof. Rama Rao Gogineni
Department of Psychiatry, Cooper Medical School of Rowan University, Camden, New Jersey
USA

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/WSP.WSP_12_19

Abstract

History of child psychiatry is interlocked with society, child-rearing, family, and many social psychiatric aspects. Children make up one-third of the world's population and are the most physically, economically, and socially vulnerable group. Mental health problems represent the largest burden of disease among young people. Worldwide, 10%–20% of children and adolescents experience mental disorders. For the last 200 years, understanding of children and adolescents, their vulnerabilities, resilience, and treatments to enhance their mental health has been exploding. As we entered the 21^st century with industrialization, urbanization, modernization, and globalization along with many aspects of our lives, children's mental health, and their rights, advocacy for their health has been of intense research and care. In this article, we address some of the most relevant topics – contributions of culture, immigration, digitalization, child maltreatment, discrimination, stigma, changes in the family structure. We also report here the efforts of the United Nations and various countries, with special emphasis on low- and middle-income countries. Finally, we also advocate various ways for children's mental health advancement from a social psychiatric perspective.

Keywords: Advocacy, changing family, children's mental health, culture, globalization, stigma

How to cite this article:
Gogineni RR, Rothe EM, Pumariega AJ. Setting the global agenda for social psychiatry: child and adolescent psychiatric perspectives. World Soc Psychiatry 2019;1:53-61

How to cite this URL:
Gogineni RR, Rothe EM, Pumariega AJ. Setting the global agenda for social psychiatry: child and adolescent psychiatric perspectives. World Soc Psychiatry [serial online] 2019 [cited 2023 Mar 24];1:53-61. Available from: https://www.worldsocpsychiatry.org/text.asp?2019/1/1/53/267959

Introduction

Children make up one-third of the world's population and are the most physically, economically, and socially vulnerable group. Currently, children under the age of 18 make up nearly 48% of the population in the world's developing countries and 21% in the industrialized nations.^[1]

Mental health problems represent the largest burden of disease among young people as among adults. Half of all mental illnesses begin by the age of 14 and three-quarters by the mid-20s, with anxiety and personality disorders sometimes beginning around age 11 and half of cases of mood disorders by adolescence. A survey across 10 countries found that around one-quarter of young people had a mental disorder. As many as 10% of boys and 14% of girls aged 11 years reported “feeling low” more than once a week in the last 6 months, on average across 28 European countries. The share of children reporting experiencing low mood increases quite sharply with age, and gender differences become even starker – as 11-year-olds, 14% of girls compared to 10% of boys felt low; however, as 15-year-olds, this gap widened with 29% of girls feeling low compared with only 13% of boys.^[2]

The United Nations (UN) Convention on the Rights of the Child states, “State parties ensure that the institutions, services, and facilities responsible for the care or protection of children shall confirm with the standards established by competent authorities, particularly in the areas of safety, health, in the number and suitability of their staff, as competent supervision. Children constitute an often-forgotten element. Yet, raising healthy, educated children is critical to the success and continuation of every nation-state.”^[3]

Epidemiology of Child and Adolescent Problems and Disorders

Worldwide, 10%–20% of the children and adolescents experience mental disorders. Neuropsychiatric conditions are the leading cause of disability in young people in all regions. If untreated, these conditions severely influence children's development, their educational attainments, and their potential to live fulfilling and productive lives. Children with mental disorders face major challenges with stigma, isolation, and discrimination, as well as lack of access to healthcare and education facilities, in violation of their fundamental human rights. Mean global coverage of prevalence data for mental disorders in ages 5–17 years was 6.7% (conduct disorder: 5.0%, attention-deficit/hyperactivity disorder [ADHD]: 5.5%, autism spectrum disorders: 16.1%, eating disorders: 4.4%, depression: 6.2%, anxiety: 3.2%). Of 187 countries, 124 had no data for any disorder. Many low- and middle-income countries (LMICs) were poorly represented in the available prevalence data, for example, no region in Sub-Saharan Africa had >2% coverage for any disorder. An estimated 43% of children under five in LMICs are at an elevated risk of poor development. One in six United States (U.S.) children aged 2–8 years (17.4%) had a diagnosed mental, behavioral, or developmental disorder. An estimated 11% of American children and adolescents have a diagnosable mental health condition that causes significant functional impairment.^[4]

Social Psychiatry: Global Agenda for Child and Adolescent Mental Health

The history of child psychiatry is interlocked with our understanding of development, child-rearing practices, and place of children in the society and with nonmedical fields, such as juvenile justice and education, all of which are socially and culturally determined. Current developments in the social, community, and public health aspects of psychiatry as a whole entail growing opportunities and obligations for child psychiatrists. Children and youth with mental disorders constitute a uniquely vulnerable population. Their problems make it difficult for them to succeed at school and live happily in their families and communities, and they place the children at heightened risk of involvement with the justice system. For many of these children, mental health problems add to existing social risk factors. Mental health problems are 2–4 times as prevalent among children in poverty, those in the child welfare system, and those in the juvenile justice system.^[5] Children in LMIC, particularly those living in disadvantaged and conflict-ridden communities, are faced with extensive unmet health and social care needs (UN International Children's Emergency Fund). A substantial body of research has also provided evidence specifically relating to children's mental health, thereby increasing our understanding regarding the impact of cumulative and interlinked risk factors found predominantly in LMIC, such as war, conflict and displacement, natural disasters, poverty, child labor, and other forms of exploitation.^[6]

In the ensuing paragraphs, various child and adolescent perspectives that should inform a global agenda for social psychiatry are outlined and discussed.

Current Topics of Importance for Global Child and Adolescent Mental Health

Cross-cultural child and adolescent mental health

Much of the epidemiological data about childhood mental health morbidity currently come from the industrialized countries, which paradoxically host a lower percentage (about 20%) of the global children and youth population. As we need to look at the mental health of children and youth population in LMICs, cross-cultural issues need be considered. The cross-cultural nuances in risk and protective factors and the plurality of nature and expression of childhood psychopathology research in developing countries need to be studied.

Across the life course, mental disorder prevalence varies significantly according to race and ethnicity, and these indicate that racial and ethnic minorities are at elevated risk of persistent mental disorders in adulthood. For example, African-American children and adolescents are less likely to develop lifetime major depression than non-Latino Whites as adults; their depression is significantly more likely to develop a chronic course. This suggests that the effects of some risk factors might accrue incrementally over time to impede recovery from mental disorders, highlighting the importance of associations of race and ethnicity with different stages of development for targeting interventions. Four social determinants were studied to understand these disparities in mental health outcomes as minority children and adolescents transition into adulthood: (i) socio-economic status (e.g., low education and income); (ii) childhood adversities (e.g., maltreatment and family violence); (iii) family structure across development (e.g., single motherhood, early child-bearing, divorce, and paternal involvement); and (iv) neighborhood-level factors (e.g., residential composition, stability, and segregation). Not only does exposure to these factors vary by race and ethnicity, but their effects might differ along the same lines. Also discussed were the potential role of individual and neighborhood-level protective factors (e.g., social support, religion and spirituality, and neighborhood stability) as buffers against the negative effects of these risk pathways and barriers to mental health care that may lead to untreated or poorly treated mental illness for minority children and youth.^[7]

Child and adolescent mental health in the digital age

Children and young people today have grown up in an era of digital technology and have been familiar with computers, mobile devices, and the Internet from an early age. On average across the OECD countries, a typical 15-year-old student in 2015 had been using the internet since age 10 and spent an average of 29 h per week on the internet. One-quarter of the students reported that they were extreme internet users during weekends, spending >6 h a day online, with 16% spending a similar amount of time online on weekdays. Children and young people are also increasingly using the internet on a variety of portable devices, where adult supervision might be more challenging. Smartphone ownership has become a common feature of teen life with nine out of ten 15-year-olds in the OECD having access to a smartphone, while three-quarters have access to a laptop, and just over half to a tablet. Only 0.3% of 15-year-olds report never having accessed the Internet.^[8]

Children and young people should be empowered and supported to use the digital technology to enable them to benefit that social media provides. Parents and caregivers should adopt an approach that works best for their child's age, interests, and needs to maximize the protection against online risks without restricting the opportunities and benefits or undermining the child's ability to explore, learn, and express themselves. Children should learn to take responsibility in reporting cyber-bullying of themselves or against others and develop proactive coping strategies, such as deleting messages or blocking unwanted contacts.^[9]

Parents and caregivers should develop digital knowledge and confidence to actively engage with technology and model constructive and balanced digital habits. Governments should promote parental controls for different devices, as well as encourage co-viewing of content with children to help children understand what they are seeing and apply it to the world around them. There is a need for research covering these parental supervisions and controls, particularly in primary school-aged or younger children, as children are utilizing digital technologies at ever-younger ages.^[8],[9]

In addition, in adolescence, this technology provides far more intense exposure to peer pressure, peer evaluation, and social ostracism. The interaction among youth, using this technology for social media, results in far-greater self-consciousness and doubts about self-image and worth. The classic expression of such is youth counting the number of “Likes” garnered on their postings on social media platforms. Some studies suggest that the degree of social media usage is associated with adverse mental health consequences among youth, including depression and suicidality.^[10]

Worldwide migration, immigration, and refugees

According to the UN Department of Economic and Social Affairs data, the estimated number of people aged 19 years or under living in a country other than the one where they were born rose from 28.7 million in 1990 to 36 million in 2017. In 2017, child migrants (aged 19 years and under) accounted for 13.9% of the total migrant population and 5.7% of the total population (of all ages). The estimated number of young migrants (aged 15–24 years) also rose from 22.4 million in 1990 to 27.9 million in 2017. In 2017, young migrants accounted for 10.8% of the total migrant population and 4.7% of the total population (of all ages).^[11]

Separation of vulnerable immigrant children from their parents on the background of chronic and acute adversity creates a perfect storm for attachment damage, toxic stress, and trauma. Children in immigration detention remain at significantly increased risk of physical, mental, emotional, and relational disorders in the short and long term. Hostility toward immigrants raises further barriers to health service engagement and risks increasing the health disparities and number of children living with unmet health needs. Such hostility then breeds reactive hostility and ethnic self-hate among children of immigrant, rendering them vulnerable to recruitment by violent extremist ideologies and groups.^[12]

Host countries have a decisive opportunity to reduce harm and promote the resilience and recovery of traumatized children by developing protective postmigration policies and processes. It is crucial that the U.S. and other countries practicing child immigration detention expedite the reunion of immigrant families and end child detention. It is also critical for policy leaders to recognize that family detention is not a “kinder” alternative and the “othering” of immigrants and normalization of suffering should never be tolerated. All forms of immigration detention are highly detrimental to children and adults, and the many effective alternatives must be considered. Pediatricians, psychiatrists, and healthcare professionals and researchers must continue to advocate for children and families exposed needlessly to immigration detention center trauma.^[12]

Discrimination/xenophobia: Causes and consequences

Discrimination and xenophobia have adverse consequences at all age groups but leave its most indelible and lasting impact on racially/ethnically diverse children and youth. They can adversely impact their identity development, impair their successful acculturation (retaining the values of their culture of origin while being successful navigating the host/mainstream culture), and lead to negative outcomes socially, in academic and work productivity, and overall successful psychosocial adaptation.^[13]

Researchers at University of California, Riverside, and Clark University, Massachusetts, studied >170 children attending schools in Southern California's Inland Empire. The children were recruited as part of a larger, ongoing study on resiliency in youth who face adversity growing up. More than half of the children were Latino, about 20% were Black, and the rest mixed raced. Children who reported discrimination and had low ethnic-racial identity scores were at high risk for anxiety, depression, and oppositional behavior and other mental health and behavior problems. However, among children with a strong sense of ethnic-racial identity, the effects of discrimination were muted. Some of the conclusions from this study include: (1) Parents can help children build their sense of identity by talking with them about their family's racial and ethnic background; (2) at school, teachers can encourage children to share information about their cultures and origins; (3) the study findings highlight the importance of counteracting negative racial stereotypes and anti-immigrant rhetoric in the media and society; (4) children from immigrant families in California are increasingly experiencing mental health problems as a result of the current political climate; (5) each of us has to make a positive impression on a child and to make sure they feel valued, they feel validated, and they feel loved and supported by the adults in their lives, regardless of their background.^[13]

The World Conference Against Racism (WCAR^[14]) made the following conclusions and recommendations.

Racism in all its horrific forms is transmitted across generations and is manifested in individual behaviors, institutional norms and practices, and cultural values and patterns
Racism serves simultaneously both to rationalize the hierarchical domination of one racial or ethnic group over other group(s) and to maintain psychological, social, and material advantages for the dominant group
Both active racism and passive acceptance of race-based privilege disrupt the mental health and psychological functioning of both victims and perpetrators of racial injustice
We strongly believe that respect for the inherent dignity and well-being of each member of the human family is the psychological foundation of freedom, human justice, and peace in the world
We urge the integration of psychological and positive mental health concerns into the framework of the WCAR as a necessary condition for the effective implementation of remedies and corrective and preventive measures and strategies
We urge governments, academic, and professional, philanthropic, religious, humanitarian, professional, and corporate institutions, nongovernmental organization (NGO), and other civil society groups, and the UN to acknowledge, protect, and promote the quality of life of victims of racism and other forms of intolerances, especially women and children, migrants and refugees, members of multiethnic states, indigenous peoples, African and African-descendent peoples, victims of disabilities, and physical and mental disorders
We establish, endorse, and actively support financially, Institutes on Racial and Ethnic Equity and Mental Health Promotion, at the highest levels. These institutes should place a high priority on research and public policy development and the promotion of research and program development related to tracking the effects of racism, racial discrimination, xenophobia, and related intolerances and the status of related racial and ethnic disparities in social, educational, economic, political, health, and psychological statuses
We establish programmatic support for mental health on a par with physical health within the World Health Organization (WHO) and the UN system. We give priority to racism, racial discrimination, xenophobia, and related intolerances as deterrents to psychological well-being and positive health and mental health, including discrimination in health and mental healthcare access and treatment and the lack of effective culturally competent education of medical and mental healthcare providers
We eliminate biases in research and diagnostic instruments, methods, and procedures that reflect and perpetuate racial and ethnic disparities and racism in medical, psychological, psychiatric, educational, employment, and other institutional assessments
We recognize and support using the impressive wealth of existing educational curricula and resources against racism at all levels of formal education to promote understanding of human rights, especially historical and intercultural approaches developed by the United Nations Educational, Scientific and Cultural Organization.

Child maltreatment

Child abuse and neglect are age-old ills that still plague humanity. As civilization has advanced and our understanding of child psychosocial development deepened, there has been greater recognition of the deleterious and lasting effects of child maltreatment, particularly in the development of lasting psychopathology. In addition, practices associated with child-rearing and interacting with children that in previous generations within some traditional cultures (in all parts of the globe) have been considered normal and even beneficial are now increasingly considered child maltreatment.^[15],[16]

While much of the focus on child maltreatment has been traditionally at the nation-state level, international bodies have become increasingly engaged in addressing child maltreatment. The WHO Global Campaign for Violence Prevention and UN Secretary General's Study on Violence Against Children made the following three important observations.^[16]

Violence is an important public health issue, directly affecting millions of individuals every year. For instance, the WHO estimates cited in the UN Secretary General's Study on Violence Against Children state that nearly 53,000 children are murdered each year and that the prevalence of forced sexual intercourse and other forms of sexual violence involving touch, among boys and girls under 18, is 73 million (or 7%) and 150 million (or 14%), respectively
Violence against infants and younger children is a major risk factor for psychiatric disorders and suicide and has lifelong sequelae including depression, anxiety disorders, smoking, alcohol and drug abuse, aggression and violence toward others, risky sexual behaviors, and posttraumatic stress disorders. Preventing violence against children therefore contributes to preventing a much broader range of noncommunicable diseases
Violence against children is highlighted in the World report on violence and health (see Chapters 2 and 3 on youth violence and child abuse and neglect) and as such is an integral part of WHO's Global Campaign for Violence Prevention and its objectives to promote uptake of the WHO Prevention Recommendations and support countries in their implementation of WHA Resolution 56.24 Implementing the recommendations of the World report on violence and health.

To help meet these prevention challenges, the WHO has collaborated with the International Society for Prevention of Child Abuse and Neglect (ISPCAN) in the development of Preventing child maltreatment: A guide for taking action and generating evidence to assist countries to design and deliver programs for the prevention of child maltreatment by parents and caregivers. The guide provides technical advice for professionals working in governments, research institutes, and NGOs on how to measure the extent of child maltreatment and its consequences; on how to design, implement, and evaluate prevention programs; and on important considerations for detecting and responding to child maltreatment. The guide is a practical tool that will help governments implement the recommendations of the recently released UN Secretary General's Study on Violence Against Children. WHO, ISPCAN, and other partners will be working intensively with a small number of selected countries to develop model prevention programs built around the guide, and WHO Headquarters and Regional and Country Offices look forward to providing advice and technical support in response to requests for assistance more generally.^[15],[16]

Changes in parenting and family structure

Families play a central role in societies as they are the primary site for reproduction, in socializing the next generation, in early education, and in stabilizing adult personality formation. Changes in families during the 20^th century and early 21^st century as a result of industrialization and globalization are characterized by greater family diversity, increasingly codified in laws. In the industrialized world, the “traditional” bread winner/homemaker family no longer constitutes the main family form or the only normative environment in which children are born and raised. Instead, single parenthood, one-person households, unmarried and same-sex cohabitation, and remarried families have become more common and are increasingly accepted as suitable living arrangements. In the developing world, we do not find the same general acceptance of diverse family forms, but we are witnessing an increase in dual-earner households, an upsurge in the number of women in the labor force, and a significant aging of populations. Globalization transmits new concepts about gender, work citizenship, identity, familial relationships, and women's and children's rights. In some places in the world, globalization is perceived as a form of enforced westernization. The response to this perception is at times a reversal to nationalistic and fundamentalist tendencies. To preserve “traditional” values and beliefs, people turn back to what they believe are the authentic customs and beliefs of their societies, sometimes even using violent means.^[17]

In developing, instituting, and monitoring social policies, we need to be aware that families act as a buffer between globalizing forces and the choices and challenges that women, men, and children face daily. Complicating the equation is the fact that globalization has varying effects and means different things depending on where people live and their particular social, political, and economic situation. We need to develop policies and procedures to address the needs of children who are the most vulnerable group.

Mental health stigma

Stigmatizing views of mental disorders and mental health services are cited as the most formidable obstacle to the receipt of mental health care (U.S. Surgeon General, 1999^[18]). A recent study of medical students in the United Kingdom revealed that student avoidance of mental healthcare was related to their stigma about mental illness, including an attitude that mental health problems were signs of weakness. Stigma identified as one of the most significant barriers to reducing the mental health treatment gap globally; mental illness stigma feeds a negative spiral of silence and suffering that leads to successive cycles of stigma and discrimination. Social exclusion, grounded on stigma, leads to poor recovery outcomes and quality of life for those suffering from mental disorders. Stigma also prevents many individuals from seeking mental health services during the early stages of their disorders.

Studies have shown in addition to broad spectrum of adult mental health stigma reduction techniques, stigma reduction in middle school health curricula with participating school staff, actively involving parents and teachers, addressing misconceptions as part of mental health, and incorporating frank discussions that challenge teens to explore their biases. Mental health providers must acknowledge that teens, who seek or are referred for services, may hold stigmatizing attitudes toward using mental health services or have individuals in their social network with these viewpoints. Therefore, addressing teen perspectives as well as the potential biases of peers and family members in treatment plans is integral. This research highlights that 8^th grade is a critical period in which youth initiative in mental health care-seeking may emerge. Family involvement, and in particular parental involvement, has been cited as a critical component of expanded school mental health programs; however, there are significant challenges with respect to parental biases that can impede their participation.

The World Psychiatric Association (WPA) Presidential Global Program on Child Mental Health carried out in collaboration with the WHO and International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) is an unprecedented worldwide activity which addresses three key elements in furthering the development of child and adolescent mental health services: awareness (anti-stigma), intervention (treatments), and prevention. The manuals and background papers prepared under this initiative will provide a global framework for advancing child and adolescent mental health.^[19]

Workforce shortages

Child and adolescent mental disorders are common and effective treatments are now available; services for those in need are largely unavailable. One of the most significant challenges in bridging the mental health treatment gap is the glaring shortage of trained mental health workers in healthcare systems worldwide.^[20]

Section on Child and Adolescent Psychiatry (CAP) of the WPA, the IACAPAP, the World Association for Infant Mental Health, the International Society for Adolescent Psychiatry and Psychology, the UN Special Rapporteur on the Right to Health, representatives of the WHO Department of Mental Health and Substance Abuse, and other experts outlined four consensus priorities for CAP over the next decade.^[21],[22]

Increasing the workforce necessary for providing care for children, adolescents, and families facing mental disorders
Reorienting child and adolescent mental health services to be more responsive to broader public health needs
Increasing research and research training while also integrating new research finding promptly and efficiently into clinical practice and research training
Increasing efforts in advocacy.

Despite increasing social demands, mostly, all the countries have been facing a serious shortage of CAP specialists. To avoid tragic consequences of unidentified and untreated mental illness in youth, we need to provide enough CAP workforce and appropriate accessibility to mental health services in partnership with the educational and child welfare systems. We need to advocate for the establishment and development of a standardized CAP training system. In addition, many LMICs have developed mental health extender programs that train paraprofessionals who serve to provide greater access to child mental health services as well as assist in implementing preventive programs at the community level.^[23] These programs should be studied and replicated. The principles of community-based systems of care developed in the U.S.^[24],[25] can be implemented within such paraprofessional programs to provide for individualized, family-focused, and least restrictive care.

Current Solutions to the Challenges of Global Child and Adolescent Mental Health: Conclusions

Below, we outline various approaches and ongoing policy programs designed to address the challenges we have previously presented around global child mental health. These are at various stages of implementation but show definite promise in addressing these important issues.

Integrating mental health and primary care: Some strategies

Integrated care means enhancing coordination between mental healthcare providers and primary care or family practitioners. Another very effective strategy that can be utilized to expand access to child mental health services is training of pediatric primary care providers to provide such care, with the consultation of child and adolescent psychiatrists and other mental health professionals. This approach is increasingly being disseminated in the U.S., with over 40 sites (some of them being statewide) providing such access. These programs are highly effective in multiplying the capacity for services through using the expertise of child psychiatrists and mental health professionals as consultants rather than front-line providers.^[26] Integration may also involve embedding mental health providers in primary care practices, where they consult on or oversee cases and see only the most challenging patients.

Another approach that can help in this endeavor is telepsychiatry, which uses the power of the Internet to conduct videoconferencing for patient evaluation, treatment, and medication management. Integrated care often includes telemedicine technology, to allow providers to consult at a distance. Increasingly, it is being used to provide care for patient and families directly at a distance using personal smart phone video.

United Nations Convention on Rights of Child

In 1989, something incredible happened. Against the backdrop of a changing world order, world leaders came together and made a historic commitment to the world's children. They made a promise to every child to protect and fulfill their rights, by adopting an international legal framework – the United Nations Convention on the Rights of the Child. Contained in this treaty is a profound idea: That children are not just objects who belong to their parents and for whom decisions are made, or adults in training. Rather, they are human beings and individuals with their own rights. The Convention says childhood is separate from adulthood and lasts until 18; it is a special, protected time, in which children must be allowed to grow, learn, play, develop, and flourish with dignity. The Convention went on to become the most widely ratified human rights treaty in history and has helped transform children's lives.^[3]

It has inspired governments to change laws and policies and make investments so that more children finally get the health care and nutrition they need to survive and develop, and there are stronger safeguards in place to protect children from violence and exploitation. It has also enabled more children to have their voices heard and participate in their societies.

Despite this progress, the Convention is still not fully implemented or widely known and understood. Millions of children continue to suffer violations of their rights when they are denied adequate health care, nutrition, education, and protection from violence. Childhoods continue to be cut short when children are forced to leave school, do hazardous work, get married, and fight in wars or are locked up in adult prisons. Global changes, such as rise of digital technology, environmental change, prolonged conflict, and mass migration, are completely changing childhood. Today's children face new threats to their rights, but they also have new opportunities to realize their rights. The hope, vision, and commitment of world leaders in 1989 led to the Convention. It is up to today's generation to demand that world leaders from government, business, and communities end child rights violations now, once, and for all. They must commit to action to make sure every child, has every right.^[3]

Prevention

Global mental health experts specifically prioritized prevention as one of the grand challenges in the field. Existing programs in child mental health and maternal mental health could be recognized and studied as components of a strategy for preventing mental illness. Targeting vulnerable groups such as LGBT individuals could be another component of an overall prevention strategy. Four priority areas are identified for focused attention to diminish the mental health treatment gap and to improve access to high-quality mental health services globally: diminishing pervasive stigma, building mental health system treatment and research capacity, implementing prevention programs to decrease the incidence of mental disorders, and establishing sustainable scaleup of public health systems to improve access to mental health treatment using evidence-based intervention

Enhancing mental healthcare for children and adolescents worldwide

The WHO initiated and approved 64 Atlas ^{More Details} projects,^[27] with evidence that points to the following steps to address and enhance adolescent health.

Public education about child mental health issues lags significantly behind other health related problems in all but the wealthiest countries. The gap in meeting child mental health training needs worldwide is staggering, with between one-half and two-thirds of all needs going unmet in most countries of the world
School-based consultation services for child mental health are not regularly employed in both the developing and developed world to the degree possible. This gap leads to a failure to reach children who otherwise might be helped to avoid many of the problems associated with school drop-out and other significant consequences
Child and adolescent mental health services funding is rarely identifiable in country budgets and in low-income countries services are often “paid out of pocket”
While the UN Convention on the Rights of the Child is identified by most countries as a significant document rarely is the child mental health-related provision of the Convention exercised
The work of NGOs in the provision of care rarely is connected to ongoing country-level programs and too often lacks sustainability.
The development and use of “self-help” or “practical-help” programs, not dependent on trained professionals, in developing countries appear to be more a myth than a reality
In 62% of the countries surveyed, there is no essential drug list for child psychotropic medication. In 53% of the countries, there are no specific controls in place for the prescription of medications
Although worldwide, there is a great interest in ADHD, in 47% of countries, psychostimulants are either prohibited or otherwise not available for use.

The World Psychiatric Association Presidential Global Program on Child Mental Health

The objectives of this program,^[19] supported by an unrestricted grant by Eli Lilly, are as follows:

To increase the awareness of health decision-makers, health professionals, and the general public about the magnitude and severity of problems related to mental disorders in childhood and adolescence and about possibilities for their resolution
To promote the primary prevention of mental disorders in childhood and adolescence and foster interventions that will contribute to the healthy mental development of children and adolescents
To offer support for the development of services for children and adolescents with mental disorders and facilitate the use of effective methods of treatment.

The WHO's Comprehensive Mental Health Action Plan 2013–2020^[28] also sets out important goals for addressing these challenges:

To strengthen advocacy, effective leadership, and governance for child and adolescent mental health
To provide comprehensive, integrated, and responsive mental health and social care services in community-based settings for early recognition and evidence-based management of childhood mental disorders
To implement strategies for the promotion of psychosocial well-being, prevention of mental disorders, and promotion of human rights of young people with mental disorders
To strengthen information systems, evidence, and research
Parent Skills Training Program for Families of Children with Developmental Delays/Disorders
The adoption of a life-cycle approach in implementation of mental health policies and strategies.

Cultural competence and diversity education and implementation within clinical care

Humankind's greatest challenge is achieving a balance between technological and social advancement while respecting diverse cultural values and traditions across the globe, refraining from imposing any cultural imperative over others as “superior.” This challenge is particularly critical for children's mental health, since culture is a major force that shapes identity, basic relations, adaptational skills, family structure, and societal order. Culture is also a major determinant of mental health, since many cultural values and beliefs can be both beneficial and protective while some can outlive their adaptational value and even become deleterious. Consideration of and respect for culture and diversity needs to be at the core of all human interaction but particularly the delivery of children's mental health services.

The cultural competence movement in the U.S. has been of great value in informing clinical services and supports with a cultural perspective. The American Academy of Child and Adolescent Psychiatry officially endorsed a Practice Parameter on Culturally Competent Child and Adolescent Psychiatric Care,^[29] which points to key areas of clinical care that intersect with culture, such as linguistic factors, history of immigration and trauma, cultural context of differential expression of symptoms and psychopathology, family involvement, child-rearing factors, principles of psychosocial interventions, evidence-based psychological approaches, and principles of pharmacotherapy. These have potential utility beyond the U.S. given the importance of this area.

Conclusions and Recommendations

The history of child psychiatry is interlocked with society, child-rearing, family, and many social psychiatric aspects
Children make up one-third of the world's population and are the most physically, economically, and socially vulnerable group
Mental health problems represent the largest burden of disease among young people. Worldwide, 10%–20% of children and adolescents experience mental disorders
For the last 200 years, understanding of children and adolescents, their vulnerabilities, resilience, and treatments to enhance their mental health has been exploding
As we entered the 21^st century with industrialization, urbanization, modernization, and globalization along with many aspects of our lives, children's mental health, and their rights, advocacy for their heath has been of intense research and care
Culture, immigration, digitalization, child maltreatment, discrimination, stigma, and changes in the family structure have great impact on children's psychology and mental health
Global efforts are being made through the leadership of the UN to enhance understanding and research, promotion of health, and advocacy for children's rights and well-being
From the social psychiatric perspective, it is imperative to adopt and implement a framework of Culturally Competent Child and Adolescent Psychiatric Care
However, we still need to further our research, advocacy to understand, promote the well-being of our future, the most vulnerable set of our globe our children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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