A. Rahman ( Department of Child and Adolescent Psychiatry, Royal Manchester Children’s Hospital, Manchester, UK. )
N. Hussain ( Department of Consultant Psychiatrist, Centre for Living and Learning, Karachi. )
Recent reports1,2 have pointed to an alarming increase in the global burden of mental disorders. These reports indicate that the impact of mental disorders has been heavily underestimated not only in the developed world but also in developing regions. when disability as well as death is taken into account. For example, unipolar major depression, ranked fourth in the world league of disabling diseases in 1990, will be second only to ischaemic heart disease by 2020.
Current research provides strong evidence that the aetiology of all mental disorders is ‘biosocial’ and that the quality of a person’s social environment is closely related to risk for mental illness. Low income countries face a multitude of social problems. including poverty, malnutrition, rapid urbanization, educational deprivation, drug abuse and breakdown of the protective influences of the family. The vast majority of the world’s children is exposed to these and many other risk factors and is at an increased risk of mental health problems. The purpose of this paper is to review some of the social and cultural issues that should be taken into account by policy-makers, planners and professionals working for child mental health in these regions.
Poverty and malnutrition
One-fifth of the world population - an estimated one billion people - live in abject poverty. The divide between the rich and the poor nations is widening. Developing countries, almost 80% of the world’s people, control only 15% of the global gross national product3. Povert\\\\ of this magnitude has Serious implications for children’s health. It is the principal cause of the 12.2 million deaths per year in children under five. UNICEF estimates that one in five child in low-income countries suffers chronic malnutrition and a similar number subsist on diets deficient in one or another nutrient. This leads to growth retardation in 230 million children and severe wasting in 50 million children. It should be noted that malnutrition occurs not only due to inadequate food supply, but also from inappropriate dietary practices such as decline in breast-feeding, lack of weaning and failure to supplement diets with essential micronutrients.
Malnutrition also seriously effects mental health of children. Poor nutrition and limited health care during pregnancy increases the likelihood of neurodevelopmental abnormalities. Post-natally, mental development is adversely affected by low birth weight, protein-energy malnutrition, iodine deficiency, iron deficiency anaemia, and deficiency of other micronutrients4,5. Malnutrition accompanied by inadequate intellectual and social stimulation results in test performance far below expected levels. Prompt attention to nourishment alongwith appropriate cognitive and social stimulation can lead to a resumption of normal development6.
Malnutrition, by depressing immunologic defence system, renders children more vulnerable to infections. This problem is compounded by the ‘non-availability or non-acceptance af immunization. The consequence can be devastating, manifesting as brain damage and dysfunction, leading to higher rates of mental retardation7 and epilepsy8.
Urbanisation and social change
Although the rural poor account for over 80% of the total number of poor people in the world9, urban poverty is growing fast, and presents its own set of problems. Between 1950 and 1985, the portion of population living in urban areas in most countries of Asia, Africa, Latin America and the Pacific has doubled and by the year 2000. nearly half of the population in these regions will reside in urban areas2.
Rahim and Cederbled10 found an increase in behavioural symptoms in Sudanese children who migrated from a rural to urban area, and Guiness11 suggests that adolescents are at the forefront of change and are particularly vulnerable to the effects of rapid social change.
There are as many as 80 million homeless children in developing countries, many of whom sleep on the streets. These children are a vulnerable group, subject to economic and sexual exploitation12. In 1980, the International Labour Organisation estimated that there were 52 million children under the age of 15 that were economically active. The numbers have increased since. Many children labour in poor working conditions and have an inferior status. They have limited opportunities for intellectual and social development and consequently suffer from poor physical and mental health13.
Rapid urbanisation and economic change have, in many countries, undermined the traditional structure and role of the family. Al Awad and Sonuga-Barke14 demonstrated more emotional and behavioural symptoms in children living in nuclear families compared to traditional extended families that had migrated to an urban area. Korbin15 suggests that the social changes associated with urbanization increase the risk for child abuse. An important issue linked to child development is maternal health. Studies show that women in urban settings suffer more distress then men16.
Social change is often dictated by developmental necessities. But many policies are shaped by political, lobbyist and media influences. These may have effects beyond the regions they were originally intended for. Eisenberg17, for example, asserts that many social policy decisions have a major impact on family life. He gives the examples of women’s rights, tax policy, divorce laws, and employment policy. He argues that explicit attention must be paid to the mental health consequences of such policy decisions. For this to be possible, the CMH professional ought to be an active and informed participant in such debates.
War, violence and natural disaster
With the exception of Eastern Europe, most armed conflicts in recent years have taken place between or within developing countries of Africa, Asia or Latin America. War and the consequent political instability and loss of infrastructure and resources predispose to malnutrition and illness, displacement of populations and fragmentation of families. Children and adolescents are often at the forefront of such conflicts. In 1995, there were an estimated 200 000 child soldiers between the ages of 6 and sixteen, 27 million refugees, and 26 million “displaced persons” within their own countries18. Recent tragic events in the Balkans have since added to these numbers. The trauma of war has serious effects on the mental health of children19,20. Psychosocial effects on children of political oppression21 and refugee camp confinement22 have been described, as have been long term effects of war trauma on resettled children23. There are million of children in need as a result of recent and ongoing conflicts in Afghanistan, Bosnia, the Gulf and Kashmir. For many developing countries, preventive, therapeutic and rehabilitative programs directed to such groups of children would need to be a priority24.
In addition to war, natural disasters such as floods, drought and earthquake effect not only the physical but also mental health of children, many of whom are orphaned and left homeless as a result of such calamities. Very few studies have looked at the long-term consequences of these disasters on the mental health of’ these children.
Education is a protective factor against a wide range of psychosocial disturbances. Early childhood education and development programs have a direct and measurable impact on both the health and nutritional status of children25. The educational level of mothers is the most robust predictor of infant mortality rates in poor societies, with lower mortality rates among infants whose mothers have achieved increasing levels of education26. Clearly. education of children has important health implications. Literacy rates in many developing countries are low. The reasons for this are manifold. Families may not afford to send children to school, who are then inducted into wageearning roles at very young ages. Many have no school to go to, while for others, schools are oppressive and unwelcome. Others may have been excluded because of unrecognised problems such as visual or hearing defects or specific learning disorders. In many societies, formal education for girls is discouraged because of cultural taboos. It would be feasible for CMH services in some areas to collaborate with the education services for the improvement of the school atmosphere and the mental health of its children.
Need for Action
In the face of these profound challenges, national and regional commitment is necessary if child mental health is to be made a priority and limited tesources are to be put to their best use. Child mental health services need to be recognized as a priority of national health and social policy; this recognition must be conveyed to important institutions and to the general public, and the commitment must be sustained. Mental health care for children must be specifically discussed in national health programmes, with a clear description of activities that will be undertaken to help the children and their families. In many countries, new legislation promoting the rights of children will need to be introduced.
A number of approaches have been tried to provide services in areas of limited resources. Most approaches employ common principles, calling for services to be decentralized, multisectoral, culturally relevant and sustainable. For example, the primary care approach espoused by WHO27 calls for integration of mental health care into the primaty care network, with support from specialised mental health personnel. The approach calls for changes in the roles and training of both general health workers and mental health professionals, emphasises the preventive and promotive aspects of mental health care, and encourages community involvement. While there are often very few child mental health professionals working in developing countries, some of whom operate in almost complete isolation. It would be useful to have some form of networking, between individual psychiatrists, psychologists, sociologists, as well as between various centers, to allow collaboration and exchange of ideas.
School health programmes have an important role to play in the health of children28. School based mental health services also have the potential for bridging the gap between need and utilization by reaching disadvantaged children who would otherwise not have access to these services29. In this way. the use of local resources and strengths can provide a sustainable basis for new developments.
In conclusion, it is clear that both broad policy considerations and public health interventions are needed to prevent mental health problems, to prevent unnecessary impairment and disability and to promote the mental health of children living in low-income countries.
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