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Child health was once equated with the absence of infectious disease, remaining on growth chart curves or being a ‘good’ child. In the 21st century none of the old parameters are sufficient to measure child health. The World Health Organization has embraced the ideal of ‘no health without mental health’,[1] and this clearly extends to global child health. In the 21st century there are new concepts and new ways to think about the mental health of children and how to intervene when necessary to ensure healthy development.

Today, children face a highly competitive society. There are heightened expectations for achievement and diminishing opportunities to achieve in areas where intellectual attainment versus vocational skills is the measure of success. The expectations for child educational achievement in most societies have risen over the decades bringing into consideration factors heretofore isolated from the mainstream of child health. For a broader segment of the population measures of child health are now more encompassing and somewhat subtler than in the past. The increasing demands for intellectual performance rather than physical prowess define group differences in ways not previously conceptualised, and alternatives become increasingly narrow for those who are intellectually and mentally challenged. At the same time there are pressures on paediatricians and others to make earlier diagnoses of potential mental health problems in the absence of definitive assessment tools.

The understanding of the need for a developmental perspective at all phases of development is critical on the part of paediatricians, child mental health professionals, educators and all concerned with the support, education and parenting of children. The recognition that cognitive achievement is essential for a successful life and at the same time recognition that IQ alone is not an adequate measurement must be incorporated in policies at all levels of society. The recognition that the emotional life of children influences and is influenced by the child's state of physical health is required of health-care providers and those making decisions about health policy. Further, there is the need for recognition that diagnosis in children is a dynamic process and that there are limitations to prediction with currently available tools.

I will focus on the aspects of global child health that intersect with mental health. As child mortality has dramatically dropped in most regions of the world and infectious disease is being displaced by chronic illness as the consuming focus on health care, the importance of mental health as a component of health is taking on a central role. We can no longer think of child mental health issues arising in the school years but must consider disorders such as autism, depression and other disorders manifesting in the pre-school child. This is not only a challenge to the paediatric clinician and colleagues but also an unprecedented opportunity for effective intervention.

John Heckman, a Nobel Prize winning economist at the University of Chicago, and colleagues in a scholarly economic analysis, has demonstrated the overwhelming cost-effectiveness of early intervention.[2] Using data from the Perry Preschool Project he showed that early intervention provided the greatest cost benefit of any other form of intervention. If this is so, why has investment in diagnosis and intervention lagged and why have mental health issues been so stigmatised? History shows that child mental health services are often the first to be cut in times of fiscal crisis and rarely does a paediatrician want to be identified as the specialist in mental health. Structural as well as emotional factors have led to this state of affairs.

The literature read by paediatricians and colleagues and mental health professionals differ thus leading to difficulty reaching a common frame of reference and understanding of the others' concerns and findings. Understanding the relationship of mental health to health has been hampered by a lack of sharing of research data, a disconnect in terminology and assumptions about negative outcomes from mental health interventions. The incentives for paediatricians to embrace mental health concerns simply do not exist in the current global economic and practice climate.

Of course, the irony is that paediatricians are the largest group of prescribers of psychotropic medication for children and adolescents.[3] This would not be a bad circumstance were it not for too often observed inadequacy of competence in the diagnostic process. The same symptoms associated with attention-deficit/hyperactivity disorder can also be associated with psychosis, an anxiety disorder and some forms of neurodegenerative disease. There is an over-reliance on medication without the appreciation that other modalities of intervention, such as, cognitive behavioural therapy may be more efficacious. Yet, the dilemma for paediatricians and other primary care providers is that mental health directly impacts adherence and compliance with medical regimens, influences risky behaviour leading to disease and disorders, and may lead to premature death.

From a global perspective it is unrealistic and unwise to assume any major change in the numbers of child psychiatrists, and this in itself would not address the mental health needs of the most vulnerable populations. What seems to be needed is a healthy dose of reality testing that recognises the importance of accurate diagnosis, the prescription of interventions that are appropriate and the recognition of the long term, serious impact of childhood mental health disorders. The current renewed emphasis on primary care that will inevitably see paediatricians as the backbone of health-care systems increases the need for training to increase the competence of paediatricians in the mental health field. In the developing world we do not see the same stigma associated with gaining the skills needed to address mental health problems in children as we do in developed countries. This observation is interesting because if we go back 50 years in the USA and other highly developed countries, the paediatrician was the diagnostician for mental health problems in the context of knowing the family, the community and capacities of the child.

In the current era there is much discussion about ‘task shifting’, distance learning, teleconferencing, tele-therapy, other forms of presumably efficient education and therapy not reliant on the costly and scarce traditional child mental health professional resources. However, each of these strategies produces its own challenges. Who provides the initial quality education to the ‘master teachers’, who selects the treatments to be expanded, where is the quality control and long-term fidelity for the treatments being utilised? It may be a false hope to think that there are significant financial gains from the proposed strategies. It is conceivable that with experience the computer-based interventions and the telemedicine approaches may spare the use of high-cost resources, but this is yet to be proven.

So, what is the solution short and long term? It is quite presumptuous to think that I have an answer. I do think that policy and educational reforms have a key role to play. Policy can support engagement through both incentives and coercion, and training can lessen the emotional barriers to engagement in areas not valued. More holistic cross-disciplinary training not unlike that of 50 years ago would help with the current dilemma.

A key to any substantive change in how child mental health is viewed and incorporated in training and clinical care is improved economic literacy. When governments, academic leaders, politicians at the local level, education and paediatric leaders recognise the demonstrated economic value for societies and communities of enhanced child mental health and remediated psychiatric disorders, changes will appear and be institutionalised. To achieve this end there needs to be a shift in educational emphasis in medical school and graduate schools towards looking at economic consequences of all interventions, not just traditional outcome measures of clinical or educational success. Lastly, there needs to be a global recognition that improving the economic and social status of mothers is a key to improved child mental health and more successful societies.

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