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The World Health Organisation (WHO) has been instrumental in highlighting the mental health needs of children and adolescents particularly in the low and middle income countries (LAMIC) context for more than 30 years. The project reported in the preceding article (Morris et al., 2011) is part of a WHO initiative to map services for child mental health. The WHO/AIMS survey has done a valuable task. Despite shortfalls, it does cover a large percentage of the world’s children and does provide a baseline in terms of available resources for children. The study also highlights very significant shortfalls of mental health services for children and adolescents. One limitation of this survey is that it does not include paediatric services, which from the point of view of child and adolescent mental health is an important omission. This survey, as well as the earlier WHO initiative of preparing country-specific Case Profile’s on Child and Adolescent Mental Health (Sartorius & Graham, 1984), not only provides new information but may also serve to highlight the situation for within-country professionals involved in data gathering. I was part of the Case Profile initiative, and this experience inspired me to lobby with colleagues for child mental health policy and primary care focused services in Sri Lanka (De Silva, Nikapota, & Vidyasagara, 1988).

The data on available services for children make for discouraging reading but are also a challenge. They present us with the reality of the situation for children in LAMIC contexts. The important questions that arise are first, how to promote positive change. Second, what role does WHO have in doing so and finally, what can established child and adolescent mental health professionals in resource-poor and resource-rich countries contribute.

The reality is that there is no likelihood of the gap closing sufficiently for children in LAMIC contexts without definite policy initiatives which include feasible steps for effective implementation, and this is recognised by Morris et al. Advocating policy is an important step. This requires motivating within-country advocates in addition to any pressure that the UN and bodies such as WHO could exert on health policy planners. Policy initiatives alone are, however, insufficient. Too often a country will develop a policy but not push the implementation, particularly if the implementation appears unfeasible or makes more demands on resources that the country can or wishes to commit.

In the discussion section, Morris et al. point to several ways in which service development in LAMIC could be improved. One important point made was that service development within LAMIC can and should focus on community-based services and that the absence of services allows for the opportunity to develop such systems. They also point out however that current trends mirror that of developed countries and have institution-based systems. Changing the trend in the desired direction will require systematic advocacy using examples from LAMIC contexts which demonstrate that alternative systems do exist. A recent review gives some examples (Patel, Flisher, Nikapota, & Malhotra, 2008). This is an area that academic professionals and clinicians can assist in developing and evaluating innovative ways of service delivery.

Task shifting and training at all levels to support services provision is another important aspect which the authors highlight. This is not a new concept. The process of task shifting has for years been associated with the cascading model of training There has been training content on child mental health developed for use in primary care and several manuals developed to aid management in primary care of stress-related problems posttrauma. Service delivery following such training has been implemented particularly postdisaster and conflict – here there is some outcome evidence available (Jordans, Tol, Komproe, & de Jong, 2009; Shoostary, Panaghi, & Moghadam, 2008), although very much more is required. Part of a future role for WHO is an exploration of these examples working within country, regional and international resource groups, including other arms of the UN family. The need as highlighted by Morris et al. is too great to allow attempts to ‘re-invent the wheel’!

The inclusion of up-to-date content with regard to child mental health in core training programmes is stressed. Perhaps this is an opportunity for support in providing accessible training content for LAMIC to use or supplement core content. This could be low cost and perhaps include internet-based teaching content which could be downloaded wherever computer facilities are available. Computing technology is increasingly popular and available in LAMIC to a sometimes surprising extent.

A further aspect which the paucity of data for the WHO/AIMS study illustrates is the lack of data – both epidemiological and in relation to outcomes. Encouraging and giving support for country-specific research would strengthen research skills as well as providing useful data including epidemiological and outcome data and may encourage countries or advocates within country to act.

The issue of extending services for child and adolescent mental health requires joint working not only within country but also among the UN family and international community. This is an aspect which could, in my view, have been demonstrated more clearly in the paper.

My final comment is to congratulate WHO on continuing the struggle to extend services for a very vulnerable group of children.

Correspondence to

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Anula Nikapota, Child and Adolescent Psychiatry Department, Institute of Psychiatry, King’s College London, De Crespigny Park, Denmark Hill, London SE5 8AF, UK. Email: anula.nikapota@kcl.ac.uk

References

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