Specific Mental Health Disorders: Child and Adolescent Mental Disorders
Further Reading
McKee M, MacLehose L and Nolte E (eds.) (2004) Health
Policy and European Union Enlargement. European
Observatory on Health Care Systems. Maidenhead, UK: Open
University Press.
Mossialos E, Dixon A, Figueras J and Kutzin J (eds.) (2002) Funding
Health Care: Options for Europe. European Observatory on Health
Care Systems. Maidenhead, UK: Open University Press.
Specific Mental Health Disorders: Child and Adolescent Mental
Disorders
A J Flisher, S Hatherill, and Y Dhansay, University of Cape Town, Cape Town, South Africa
ã 2008 Elsevier Inc. All rights reserved.
Introduction
Reviews of the prevalence of child and adolescent psychi-
atric disorders indicate that about one in five children and
adolescents suffer from such disorders (Table 1) some
examples of which are provided in Table 2 (World Health
Organization, 2005b; Patel et al., 2008 ). This estimate
appears to be applicable to both genders, a range of ages
within childhood and adolescence, all social classes, and
both high-, low-, and middle-income countries. In this
article, we have confined ourselves to psychiatric disor-
ders in the narrow sense of the term. We have not
addressed intellectual or learning disabilities.
Etiology
Whether a mental disorder develops in an individual and
arises depends on the interplay between risk and protec-
tive factors. Risk factors are factors that increase the
probability of developing a mental disorder, while protec-
tive factors moderate the effects of exposure to risk in the
presence of one or more risk factors. For example, a
person may have a strong family history of depression
and thus be genetically predisposed to suffer from depres-
sion. Loss of a parent in adolescence may serve as another
risk factor, which may then precipitate a major depressive
episode. However, if such a person has strong connections
with other family members, school, and community, such
a depressive episode may be averted. In this case, the
adolescent may experience a normal grieving process,
which does not significantly adversely affect academic
progress, relationships with peers, and physiological con-
comitants such as appetite disturbance and fatigue. This
147
Relevant Websites
http://www.aspher.org – Association of Schools of Public Health in the
European Region (ASPHER).
http://www.eupha.org – European Public Health Association (EUPHA).
http://www.snz.hr/ph-see – Public Health Collaboration in South
Eastern Europe (PH-SEE): A project of the Stability Pact.
http://www.euro.who.int/hfadb – World Health Organization. Health for
All Database. WHO.
exemplifies the complex interaction of risk and protective
factors at different ecological levels (Table 3) (World
Health Organization, 2005b).
Public Health Significance
It is important to recognize that these disorders do not
represent minor and transient responses to the normal
challenges faced by children and adolescents. If this were
the case, child and adolescent mental disorders would
have limited public health significance. On the contrary,
they are associated with a great degree of impairment and
burden, longitudinal course into adulthood, long-term
economic implications, associations with risk behavior,
and stigma, each of which will be addressed below.
Impairment and Burden
The term impairment refers to interference with psycho-
logical or physical functions in one or more of the follow-
ing domains: Interpersonal relationships, academic/work
performance, social and leisure activities, and the ability
to enjoy and obtain satisfaction from life. By definition,
impairment always accompanies the presence of a psychi-
atric disorder, as impairment is a necessary condition for
existence of a psychiatric disorder according to the diag-
nostic systems in common use. Indeed, if impairment is
not included in the diagnostic criteria, the prevalence of
child and adolescent psychiatric disorders in the general
population would be two or three times the generally
accepted prevalence. However, the extent of impairment
varies according to diagnosis, with phobias being the least
likely to be associated with impairment, followed by anxiety
148 Specific Mental Health Disorders: Child and Adolescent Mental Disorders

Table 1 Selected studies of the prevalence of child and childhood and adolescence specifically. However, among
adolescent psychiatric disorders in children and adolescents 15–44-year-olds, we know that five of the ten leading
Age range Prevalence causes of DALYs lost are psychiatric disorders (unipolar
Setting (years) (%) depressive disorders, alcohol use disorders, self-inflicted
injuries, schizophrenia, and bipolar mood disorder) (Murray
Australia 18–24 27.0
Brazil 7–14 12.7
and Lopez, 1996). Furthermore, there is an important
Canada, Ontario 4–16 18.1 mental health or behavioral contribution to the etiology
Ethiopia 1–15 17.7 of a further three of the ten leading causes DALYs lost
Germany 12–15 20.7 (HIV/AIDS, road-traffic accidents, and violence). It is
India 1–16 12.8 probable that similar findings are applicable to child-
Hawaii 13–19 26.0
Japan 1–16 15.0
hood and adolescence. Such data have contributed to an
Netherlands 13–18 8.4 increased appreciation of the public health importance of
Spain 8, 11, 15 21.7 psychiatric disorders.
Switzerland 1–15 22.5
United Kingdom 13–15 29.4
United States
. High-risk Native Americans, 14–16 29.4 Longitudinal Course of Mental Disorders in
Northern Plain reservation Childhood and Adolescence
. North Carolina 13 12.7
14 9.7 There are two types of studies that address the longitudi-
15 14.2 nal course of child and adolescent psychiatric disorders.
16 12.7
. Service users in five sectors of
First, there are studies that look back, by documenting the
12–15 57.4
care, San Diego, CA proportions of people with disorders in adulthood that
had an age of onset in childhood or adolescence. The most
Data from Patel V, Flisher AJ, Nikapota A, and Malhotra S (2008) sophisticated of these studies was conducted by Kessler
Promoting child and adolescent mental health in low and middle
income countries. Journal of Child Psychology and Psychiatry;
et al. (2005). They reported that 75% of all adults with
World Health Organization (2005b) Child and Adolescent Mental psychiatric disorder had an age of onset of 24 years or less,
Health Policies and Plans: Mental Health Policy and Service 50% had an age of onset of 14 years or less, and 25% had
Guidance Package. Geneva: World Health Organization and cita- an age of onset of 7 years or less. For anxiety disorders, the
tions therein. corresponding ages were 21, 11, and 6 years or less.
Second, there are studies that look forward. There is
disorders and finally major depressive disorder and exter- good evidence of continuity of disorders that manifest
nalizing disorders such as conduct disorder and attention themselves in childhood or adolescence into adulthood.
deficit hyperactivity disorder. Furthermore, the extent of In major depressive disorder, for example, depressed ado-
impairment is correlated with factors, independent of the lescents are at two to seven times increased odds of being
nature of the psychiatric disorder. These include the extent depressed as adults. Furthermore, about one-third of chil-
of comorbidity, either a long or short duration of psycho- dren or adolescents with a major depressive disorder will
pathology, psychosocial adversity (in generalized anxiety later develop bipolar disorder, and this is more likely
disorder), and mothers’ ratings of the extent of conduct if there is a family history of bipolar disorder, psy-
features (in children with conduct disorder). chotic symptoms, or a manic response to antidepressants.
Angold et al. (1998) reported that there is a positive Attention deficit hyperactivity disorder has three possible
association between impairment and parental perceived outcomes in adulthood, each of which occurs in about
burden of care, although the direction of the causality has one-third of children with the disorder: (1) Develop-
yet to be elucidated. The perceived burden of care was mental delay, in which over the course of time the individ-
predicted by the child or adolescent’s total symptom ual no longer manifests impairing symptoms; (2) continual
score, the child or adolescent’s level of impairment, the display, in which impairment related to ADHD persists
presence of externalizing disorders (as opposed to inter- into adulthood, although there are insufficient signs and
nalizing disorders), and the existence of preexisting men- symptoms for the diagnosis to be conferred; and (3) devel-
tal health problems on the part of the parent. opmental decay, in which the diagnosis remains applicable
A further aspect of burden is the burden imposed by in adulthood, often accompanied by other psychopathol-
the disability suffered by the child or adolescent with ogy such as substance abuse and personality disorder.
a psychiatric disorder. This can be quantified by the Autistic disorder almost always is associated with lifelong
disability-adjusted life years (DALYs) that are lost, which impairment. However, there is considerable variation in
includes loss due to both mortality and disability, for outcome, with about 15% achieving independence in
each disorder. We do not have estimates of the DALYs adulthood and a further 15–20% being able to function
lost due to child and adolescent psychiatric disorders in independently with periodic support.
 Specific Mental Health Disorders: Child and Adolescent Mental Disorders 149

Table 2 Examples of some common and/or important child and adolescent mental disorders

Attention deficit hyperactivity A persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe
disorder (ADHD) than typically observed in children at a comparable level of development
Autistic disorder The essential features are onset before the age of three; qualitative impairment in social
interaction; qualitative impairment of verbal and nonverbal communication; and disturbed
motor behavior or activities as manifest, for example, by stereotyped body movements
Conduct disorder Repetitive and persistent pattern of behavior, lasting at least 12 months, in which the basic rights
of others and major age-appropriate societal norms or rules are violated
Delirium Transient and usually reversible mental disturbance that has fluctuating symptoms that usually
develop over hours or days. Clinical features include the following: fluctuating awareness and
attention; disturbed sleep–wake cycle; restlessness, irritability, anxiety, emotional lability OR
decreased psychomotor activity; disorientation; disorganized thinking; memory impairment;
and hallucinations and other perceptual disturbances
Generalized anxiety disorder The essential feature of this disorder is excessive or unrealistic anxiety or worry, for example about
achieving and about future events such as wars or world catastrophes
Major depressive disorder A major depressive disorder is present if there is an onset of either depressed or irritable mood or loss
of interest in former pleasurable activities lasting for a period of at least 2 weeks, accompanied by
several of the following: increased or decreased appetite; insomnia or hypersomnia; increased or
decreased motor activity; difficulty concentrating with fall-off in school work; feelings of
worthlessness or guilt; fatigue or loss of energy; and suicidal thoughts or behavior
Obsessive-compulsive disorder In this disorder, there is the presence of obsessions or compulsions or both, which are recognized
as excessive or unreasonable
Panic disorder There are recurrent panic attacks in which intense fear is accompanied by acute somatic
symptoms of anxiety
Posttraumatic stress disorder This disorder is present if there are recurrent, distressing, and intrusive images or flashbacks of the
(PTSD) traumatic experience; marked avoidance of particular people, places, or other reminders of the
experience; and symptoms of anxiety or increased sympathetic arousal as manifest, for
example, by difficulty sleeping, poor concentration, exaggerated startle response, and
restlessness. Depression, anxiety, and conduct disorder may accompany PTSD, or be an
alternative outcome to traumatic experiences
Schizophrenia In schizophrenia one finds delusions, hallucinations, disorganized speech, catatonic behavior, and
negative symptoms
Separation anxiety disorder There is excessive and persistent anxiety (lasting for at least 4 weeks) about separation from those
to whom the child is attached

In conclusion, there is evidence from retrospective and
prospective studies of considerable continuity of psychi-
atric disorders from childhood to adulthood. This clearly
provides support for increased resources to be allocated to
child and adolescent psychiatric services, although evi-
dence is currently sparse that early intervention will
result in improved long-term prospects.
Long-Term Economic Implications of Child and
Adolescent Mental Disorders
Given the continuity of psychiatric disorders from child-
hood or adolescence into adulthood, one would expect
that there would also be economic implications of child
and adolescent psychiatric disorders that would persist
into adulthood. Such economic costs can be direct or
indirect. The former are generally easier to evaluate and
reflect pharmaceutical costs, primary health-care costs,
emergency department visits, and outpatient and inpatient
care. The latter are generally more difficult to evaluate and
reflect the caregiver costs, unemployment, decreased pro-
ductivity, and increased demand on the education, social
services, and criminal justice systems. Existing data on the
long-term economic implications of child and adolescent
psychiatric disorders are scanty and confined to the direct
costs of a subset of disorders in the US and the UK (Romeo
et al., 2005). However, the existing data confirm that the
long-term costs associated with child and adolescent psy-
chiatric disorders are large. For example, the treatment
costs for youth with ADHD are approximately double
those for youth without ADHD; the cumulative costs of
public services utilized through to adulthood by indivi-
duals with antisocial behavior in childhood were ten
times higher than for those with no antisocial behaviors
by the age of 28 years, and the annualized cost in adulthood
for those who suffered from both depression and conduct
disorder was more than double that of the group with major
depression alone (Romeo et al., 2005).
It can be seen that the potential economic impact of
successfully implementing proven prevention and early
intervention strategies for children with disruptive behav-
ior disorders is enormous (World Health Organization,
2005b). The characteristically recurring nature of the
mood disorders and the strong evidence for their conti-
nuity into adult life would seem to suggest an equally
compelling argument for early intervention and even
150 Specific Mental Health Disorders: Child and Adolescent Mental Disorders

Table 3 Selected risk and protective factors for mental health of children and adolescents

Domain Risk factors Protective factors

Biological Exposure to toxins (e.g., tobacco and alcohol) in Age-appropriate physical development
pregnancy Good physical health
Genetic predisposition Good intellectual functioning
Head trauma
Hypoxia at birth and other birth complications
HIV infection
Malnutrition
Other illnesses
Psychological Learning disorders Ability to learn from experiences
Maladaptive personality traits Good self-esteem
Sexual, physical, and emotional abuse and neglect High level of problem-solving ability
Difficult temperament Social skills
Social
a) Family Inconsistent care giving Family attachment
Family conflict Opportunities for positive involvement in family
Poor family discipline Rewards for involvement in family
Poor family management
Death of a family member
b) School Academic failure Opportunities for involvement in school life
Failure of schools to provide an appropriate Positive reinforcement from academic achievement
environment to support attendance and learning Identity with a school or need for educational
Inadequate/inappropriate provision of education attainment
c) Community Lack of community efficacy Connectedness to community
Community disorganization Opportunities for constructive use of leisure
Discrimination and marginalization Positive cultural experiences
Exposure to violence Positive role models
Lack of a sense of place Rewards for community involvement
Transitions (e.g., urbanization) Connection with community organizations including
religious organizations

From World Health Organization (2005b) Child and Adolescent Mental Health Policies and Plans: Mental Health Policy and Service
Guidance Package. Geneva: World Health Organization.

prevention in an effort to divert children from a possible treatment interventions that address either risk behavior
trajectory of lifelong difficulties associated with substan- or psychiatric disorders would benefit from addressing the
tial individual and societal costs. other aspect.

Associations with Risk Behavior Stigma

There is robust international evidence that there is
covariation between risk behaviors such as violent behav-
ior, sexual behavior, suicidal behavior, dangerous road-
related behavior, and use of tobacco, alcohol, and other
drugs (Flisher et al., 2000). Furthermore, this cluster of risk
behaviors appears to share common correlates, for exam-
ple psychiatric disorder (Flisher et al., 2000). This has been
established both for the cluster as a whole and individual
components of the cluster. What is not clear is the direc-
tion of the causal relationship. Thus, the psychiatric disor-
der could cause the risk behavior or the risk behavior could
cause the psychiatric disorder or they could both be caused
by other factors. It is probable that the nature of the rela-
tionship varies according to the particular risk behaviors
and psychiatric disorders in question. However, whatever
the nature of the relationship, there are clear implications
for public health. Specifically, preventive, promotive, or
The term stigma is derived from a Greek word and refers
to a mark that denotes a shameful quality in the individual
thus marked. It is a complex phenomenon that is modified
by the culture and contexts in which it occurs. There are
five interrelated processes that combine to create stigma:
(1) people identify and label human characteristics, and
differences that are regarded as relevant and consequen-
tial are determined; (2) stereotyping takes place in that
the labeled person is associated with undesirable charac-
teristics; (3) there is separation of the stigmatized group
(them) from those who are stigmatizing (us); (4) the stig-
matized group experiences discrimination and loss of sta-
tus; and (5) the stigmatizing group exercises power. The
association of mental illness with irrational, dangerous, and
unpredictable behavior and the misconception that mental
illness is not a true illness has resulted in those with psy-
chiatric disorders being subject to stigmatization.
 Specific Mental Health Disorders: Child and Adolescent Mental Disorders
Psychiatric patients and their families are doubly
challenged: They are faced with the struggle caused by
their impairment and they are confronted with chronic
stress caused by the stigma that is associated with psychiat-
ric disorders. As a result of these challenges, they are
deprived of the opportunities such as good schooling and
wide social networks, which in turn adversely affect self-
esteem, and hence academic performance and economic
well-being. Children and adolescents are particularly vul-
nerable to stigma for four main reasons (World Health
Organization, 2005b):
. They are less likely to be able to advocate on their own
behalf;
. Immature cognitive development results in children and
adolescents being more likely to think dichotomously
about opposites such as good and bad, and thus more
likely to temper negative with other, less negative or
positive, responses, and hence accept negative labels;
. The stigma suffered by children and adolescents may
also affect the parents, which in turn could affect the
quality of parenting that they are able to offer;
. There is limited understanding of child and adolescent
psychiatric disorders, which implies that symptoms that
are attributable to a psychiatric disorder may be attrib-
uted to other causes, such as passive aggression in the case
of depression or overt oppositionality in the case of
attention deficit hyperactivity disorder; and their psychi-
atric disorders may persist into adulthood, which implies
that any effects of stigma may persist for equally long.
Interventions for Child and Adolescent
Mental Disorders
Mental Health Promotion
The aim of mental health promotion is to enhance posi-
tive mental health, which can be defined as the:
. . . capacity to achieve and maintain optimal psychologi-
cal functioning and well-being. It is directly related to the
level reached and competence reached and competence
achieved in psychological and social functioning . . .
Child and adolescent mental health includes a sense of
identity and self-worth; sound family and peer relation-
ships; an ability to be productive and to learn; and a
capacity to use developmental challenges and cultural
resources to maximize development (Department of
Health, Republic of South Africa, 2003: 4).
The focus is on enhancing protective factors through
goals such as strengthening individuals, strengthening
communities, and removing barriers to good mental
health (Table 4) (Funk et al., 2005). What is the relevance
of mental health promotion for child and adolescent
mental disorders? The relevance is that mental health
promotion interventions arguably also contribute to
151
Table 4 Examples of child and adolescent mental health
promotion interventions
Domain Interventions
Strengthening Develop self-efficacy (the perception that
individuals one can achieve desired goals through
one’s own action)
Encourage self-determination
Enhance life skills of adolescents
Foster belief in the future
Improve the quality of parent–infant
relationship
Nurture a clear and positive identity
Promote competencies in the social,
emotional, cognitive, behavioral, and
moral domains
Recognize positive behavior
Strengthening Develop facilities and structures to enable
communities constructive and healthy use of leisure
time of children and adolescents
Establish prosocial norms
Improve social connectedness of schools
and neighborhoods
Promote bonding (emotional attachment
and commitment) with family, peer group,
school, community, and culture
Provide opportunities for prosocial
involvement with family, peers, and adults
Removing Develop and implement economic policies
barriers to that reduce poverty
good mental Develop and implement legislation that
health protects the human rights of children and
adolescents, for example around
trafficking and sexual and physical abuse
Improve access to good-quality education
and health services
Funk M, Gale E, Grigg M, Minoletti A, and Yasamay MT (2005)
Mental health promotion: An important component of a national
mental health policy. In: Herman H, Saxena S, and Moodie R (eds.)
Promotion Mental Health: Concepts, Emerging Evidence, Practice,
pp. 216–225. Geneva, Switzerland: World Health Organization.
reducing the prevalence of child and adolescent mental
disorders. However, the empirical justification for this
statement is currently somewhat flimsy, partly because
of the methodological challenges of demonstrating out-
comes of upstream interventions (such as those men-
tioned above) on downstream outcomes such as specific
disorders in specific individuals (Patel et al., 2008).
Mental Disorder Prevention
In contrast to mental heath promotion, mental disorder
prevention aims to reduce the prevalence of specific dis-
orders, by focusing on risk factors. There are a number of
interventions for specific disorders that have been shown
to be effective, at least for populations in high-income
countries. Examples of disorders and interventions that
have been shown to be effective include (Durlak and
Wells, 1997; World Health Organization, 2004):
152 Specific Mental Health Disorders: Child and Adolescent Mental Disorders
. Alcohol misuse: School-based individual-level education
and skills training combined with a mass media cam-
paign, parent education and organization program, train-
ing community leaders and local policy changes;
. Anxiety: Teaching skills to manage anxiety symptoms
more effectively;
. Conduct disorder: Child or adolescent behavior manage-
ment, social skills for child or adolescent, multimodal
school programs, and prenatal or early childhood
programs;
. Depression: Improving cognitive and problem-solving
skills, group interventions that focus on cognitive style
and problem solving;
. Pathological eating behavior: Increasing self-esteem
and improving general eating habits and behavior;
. Schizophrenia: Low-dose neuroleptic medication and
cognitive behavior therapy;
. Suicide: School-based intervention with school suicide
policy, teacher consultation and training, education to
parents, stress management and life skills curriculum,
and a crisis team.
Treatment
It is important to develop a comprehensive treatment plan
for each child or adolescent and the family, which requires
psychiatric services. This plan should:
. address each problem or disorder that was identified in
the assessment;
. aim to modify all modifiable etiological factors in the
biological, psychological, and social domains;
. involve both the family and the child or adolescent in
treatment;
. include all contributory settings, especially the school;
. make use of the unique contributions of all appropriate
members of the clinical team.
There is a rapidly expanding evidence base on the
efficacy and effectiveness of interventions for child and
adolescent mental disorders. Specifically, there is good
evidence of the effectiveness of certain antidepressant
and antipsychotic agents and of psychotherapy (especially
behavioral and cognitive behavioral treatments for anxi-
ety and mood disorders) (Evans et al., 2005).
The Current Response
We have argued above that the public health significance
of child and adolescent mental disorders is enormous, and
that there is evidence that preventive and treatment inter-
ventions (at least) can be effective. In light of these con-
siderations, the response on the part of the health and
other systems has been insufficient to meaningfully
address the gap between the need for interventions and
the available services. Only 7% of countries worldwide
had a clearly articulated, stand-alone child and adolescent
mental health policy (World Health Organization, 2005a).
However, a larger proportion of countries have child
and adolescent mental health content integrated into
other policies, and/or have child and adolescent mental
health programs. The proportions of counties with any
child and adolescent mental health policy or programs are
lowest in the Africa region, where 33% have the former
(generally integrated into policy documents from other
sectors such as child protection, social welfare, education,
or human rights), while 6% have the latter (World Health
Organization, 2005a). The corresponding figures for
Europe are 96% and 67%. It is ironic that those countries
with the largest proportion of children and adolescents
are least likely to have a child and adolescent mental
health policy. Other selected key aspects of the current
situation include:
. There are no countries that have a data information
system for child and adolescent mental health service
outcomes at the national level.
. In the vast majority of countries outside of North
America and Europe, systems for the care of children
and adolescents with mental disorders do not exist, and
when they do exist they are based in hospitals or custo-
dial settings with minimal or no community-based
services.
. Even when services are present, there are consider-
able barriers to accessing it, such as stigma, lack of trans-
portation, inability to pay for services, inability of the
service providers to communicate effectively in the ser-
vice users’ home language, and lack of public knowledge
about mental disorders in children and adolescents.
. In countries in all economic categories, these services are
generally paid for by temporary and vulnerable sources
of funding such as the service user (or their family),
nongovernmental organizations and international grants,
as opposed to more stable government funding.
The Way Forward
The first step in responding to the scenario is to develop a
child and adolescent mental health policy with an asso-
ciated plan. The WHO has published a guideline on how to
develop a child and adolescent mental health policy and
plan (World Health Organization, 2005b), which provides a
step-by-step approach that can be used by policy makers
and planners. The steps for developing a policy are as
follows: gather information and data for policy development;
gather evidence for effective strategies; undertake consulta-
tion and negotiation; exchange with other countries; set
out the vision, values, principles and objectives of the
 Specific Mental Health Disorders: Child and Adolescent Mental Disorders
policy; determine the areas for action; and identify the roles
and responsibilities of the various stakeholders. The steps
for developing a plan are as follows: determine the strategies
and time frames; set indicators and targets; determine the
manor activities; and determine the costs, available
resources and the budget. The plan should be backed up
by sufficient resources and political will to ensure wide-
spread implementation.
It is not appropriate to specify in detail the outcomes of
the process of developing policies and plans for a country,
province, region, or district. Indeed, as is obvious from the
steps that have just been listed, this would contradict the
letter and spirit of the guidelines. However, a broad con-
sensus has emerged in recent years as to the key standards
that should characterize a child and adolescent mental
health service, whether in a high-, middle-, or low-
income country, which are summarized in Table 5.
Conclusion
Far from being minor or transient variations in response
to childhood adversity, or a medicalization of society’s
intolerance of challenging childhood behaviors or inade-
quate parenting, it has become increasingly apparent that
Table 5 Key standards for child and adolescent mental
health service planning and provision
Core features of child and adolescent mental health services
. Include child and adolescent mental health in primary health
care practices
. Provide a continuum of services
. Balance promotion, prevention, treatment, and rehabilitation
. Prioritize children and adolescent most at risk
Evidence and service planning
. Assess levels of service provision and need regularly
. Use this information to plan and commission appropriate
services
. Involve parents/families and communities in service planning
Range of services, staffing, and facilities
. Offer early intervention and mental health promotion in all
facilities
. Coordinate and integrate services across health, education,
social care, youth justice, and voluntary sector agencies
. Use a multidisciplinary team approach
. Train, supervise, and support all staff to provide a full range of
interventions
. Ensure that care is developmentally appropriate
. Keep children’s mental health-care facilities separate from
adults
. Offer services as near to home as possible and in
child-centered settings, such as schools, youth clubs,
the media, and the family
Adapted from Dawes A, Lund C, Kafaar Z, Brandt R, and Flisher
AJ (2004) Norms for South African Child and Adolescent Mental
Health Services (CAMHS) Report for the Directorate: Mental
Health and Substance Abuse National Department of Health
(Tender number DOH 48/2003–2004) Cape Town: Human
Sciences Research Council and University of Cape Town.
153
mental disorders presenting for the first time in childhood
and adolescence represent serious conditions associated
with markedly impaired functioning and significantly
lower quality of life, for both the child or adolescent and
their families. Even child or adolescent disorders tradi-
tionally viewed as mild, such as the anxiety disorders, are
increasingly being construed as possible precursors of
more serious and enduring mental health problems. In a
substantial proportion of cases, psychiatric diagnosis in
childhood or adolescence foreshadows psychiatric diag-
nosis in adulthood. An alternative view would suggest that
child and adolescent psychiatric disorders provide us with
a tantalizing window of opportunity for changing this
gloomy trajectory. The exciting challenge for child mental
health services is the prevention and early detection of
these disorders; the implementation of evidence-based
interventions with both short- and long-term clinical
and cost effectiveness; and the development of mental
health systems that ensure equitable access to such inter-
ventions. We are in the earliest stages of meeting this
challenge and exploiting this opportunity.
See also: Adolescent Health; Child Abuse/Treatment;
Mental Health and Substance Abuse; Mental Health
Policy; Mental Illness, Historical Views of; School Health
Promotion; Social Gradients and Child Health; Specific
Mental Health Disorders: Eating Disorders; Specific
Mental Health Disorders: Mental Disorders Associated
With Aging; Specific Mental Health Disorders: Trauma
and Mental Disorders.
Citations
Angold A, Messer S, Stangl D, et al. (1998) Perceived parental burden
and service use for child and adolescent psychiatric disorders.
American Journal of Public Health 88: 75–80.
Department of Health, Republic of South Africa (2003) National Policy
Guidelines for Child and Adolescent Mental Health. Pretoria, South
Africa: Department of Health Republic of South Africa.
Dawes A, Lund C, Kafaar Z, Brandt R, and Flisher AJ (2004) Norms for
South African Child and Adolescent Mental Health Services
(CAMHS) Report for the Directorate: Mental Health and Substance
Abuse National Department of Health (Tender number DOH 48/
2003–2004) Cape Town, South Africa: Human Sciences Research
Council and University of Cape Town.
Durlak JA and Wells AM (1997) Primary preventive mental health
programs for children and adolescents: A meta-analytic review.
American Journal of Community Psychology 17: 5–18.
Evans DL, Foa EB Gur RE, et al. (eds.) (2005) Treating and Preventing
Adolescent Mental Health Disorders: What We Know and What We
Don’t Know. A Research Agenda for Improving the Mental Health of
Our Youth. Oxford, UK: Oxford University Press.
Flisher AJ, Kramer RA, Hoven CW, et al. (2000) Risk behavior in a
community sample of children and adolescents. Journal of the
American Academy of Child and Adolescent Psychiatry 39:
881–887.
Funk M, Gale E, Grigg M, Minoletti A, and Yasamy MT (2005) Mental
health promotion: An important component of a national mental
154 Specific Mental Health Disorders: Child and Adolescent Mental Disorders
health policy. In: Herrman H, Saxena S, and Moodie R (eds.)
Promoting Mental Heath: Concepts, Emerging Evidence, Practice,
pp. 216–225. Geneva, Switzerland: World Health Organization.
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and adolescent mental health in low and middle income countries.
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Specific Mental Health Disorders: Depressive and Anxiety Disorders
I B Hickie, The University of Sydney, Sydney, NSW, Australia
ã 2008 Elsevier Inc. All rights reserved.
Introduction
Following the development of standardized diagnostic
systems in the early 1980s (e.g., Research Diagnostic
Criteria of Spitzer and colleagues and the DSM-III of
the American Psychiatric Association) and their incor-
poration into large-scale epidemiological studies, there
has been widespread acceptance of the dimensional nature
of the common anxiety and depressive disorders. Such
dimensional concepts can be readily incorporated into
large-scale population-health and health service develop-
ment plans. Importantly, they place an emphasis on detec-
tion and active management of the very common mild and
moderately severe cases. In this environment, the center
of clinical management is shifted from specialist care set-
tings (for more severe, prolonged, treatment-resistant,
comorbid and medically complicated) to primary care.
These broad concepts of depression and anxiety have
predictive value for key outcomes such as response to
available treatments, disability, and premature death. They
incorporate the key symptom domains (e.g., affective, cog-
nitive, sleep–wake cycle, somatic, behavioral, and self-
harm) and they can also be readily incorporated into
public and professional education campaigns as well as
Further Reading
Breinbauer C and Maddelino M (2005) Youth: Choices and Change:
Promoting Healthy Behaviors in Adolescence. Washington, DC:
PAHO.
Kazdin A and Weisz J (2003) Evidence-Based Psychotherapies for
Children and Adolescents. New York: Guildford Press.
World Health Organization (2001) The World Health Report 2001: New
Understanding, New Hope. Geneva, Switzerland: World Health
Organization.
Relevant Websites
http://www.aacap.org – American Academy of Child and Adolescent
Psychiatry.
http://www.hcp.med.harvard.edu/icpe/ – International Consortium in
Psychiatric Epidemiology.
http://www.mentalhealth.samhsa.gov/cmhs/surgeongeneral/ – Mental
Health: Report of the Surgeon General (USA).
http://www.who.int/topics/mental_health/en/ – World Health
Organization mental health page.
http://tinyurl.com/bs8zl – World Development Report 2007:
Development and the Next Generation.
everyday clinical practice. For example, simple checklists
can be widely circulated through e-health, media, print,
and health-care distribution systems (see Figure 1 for an
example from the SPHERE-program in Australia).
Clinical debate as to the best ways to describe the rela-
tionship between different anxious and depressive pheno-
types (e.g., mixed anxiety and depression, generalized
anxiety and its relationship to dysthymia (symptoms of
depression), and major depression), and between different
depressive dimensions (e.g., major versus minor depres-
sion and unipolar versus bipolar spectrum disorders) will
continue until more discrete pathophysiological pathways
are identified. The development of future international
diagnostic systems (e.g., DSM-V) has signaled this neces-
sary move from over reliance on imprecise cross-sectional
phenotypes to diagnostic categories based on putative
causal paths.
A great deal of academic effort has been expended in
epidemiological and clinical studies that seek to differen-
tiate anxiety from depressive disorders or subtype the
multiple and complex presentations of these conditions.
These efforts have reflected traditional but simplistic
belief systems about causality (e.g., psychosocial vs. bio-
logical) or the relevance of subtyping to the selection