Up to 1 in 5 children in developing countries has a mental health problem, yet treatment is woefully inadequate

Mental health problems affect 10-20% of children and adolescents worldwide. Despite their relevance as a leading cause of health-related disability in this age group and their longlasting effects throughout life, the mental health needs of children and adolescents are neglected, especially in low-income and middle-income countries. The second paper in The Lancet Series on Global Mental Health looks at the evidence for action in this especially vulnerable group. The paper is by Professor Atif Rahman, University of Liverpool, Institute of Psychology, Health and Society, Child Mental Health Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK, and colleagues.

Children and adolescents constitute almost a third (2•2 billion individuals) of the world's population and almost 90% live in low-income and middle-income countries (LMIC), where they form up to 50% of the population. For young people, neuropsychiatric disorders are a leading cause of health-related burden, accounting for 15󈞊% of the disability-adjusted life-years (DALYs) lost during the first three decades of life. The authors say that only 10% of trials of mental health interventions come from LMIC, and most of these are for drug-based interventions not psychosocial strategies. However, the authors state that sufficient evidence exists to establish and/or scale up services, since reports from disadvantaged groups in high-income countries can provide indirect evidence of effectiveness. But progress is hampered by lack of government policy, inadequate funding, and a death of trained clinicians. That less than a third of countries have an entity in charge of mental health programmes for children and adolescents illustrates the chronic neglect in this area.

The recently published WHO mental health GAP (WHO mhGAP) intervention guide provides details of various evidence based techniques that would be effective in LMIC. Many such interventions, eg, parent and teacher training for behavioural problems and community-based rehabilitation for intellectual and developmental disorders, rely on family-members and non-specialists. Many LMIC are characterised by strong family and community networks which could be used effectively to improve access to these evidence-based interventions. Support of child and adolescent mental health research is needed, particularly in LMIC, including adaptation of existing intervention strategies and developments of new ones, high-quality clinical trials, and cost-effectiveness analyses. Bodies such as the UNICEF need to broaden the scope of their psychosocial programmes to include specific childhood mental and neuropsychiatric disorders so that countries can be pressured to address the gaps in child mental health policy.

The authors point out that almost all LMIC are undergoing substantial political, social and demographic change, exposing the young to increased risk. Intervening early could prevent a substantial mental health burden in later life. Such early interventions would also improve personal wellbeing, educational opportunity and productivity in what would be some of the most productive working years of this younger person.

The authors conclude: "The promotion of child and adolescent mental health is a worldwide challenge, but a potentially rewarding one. Accumulating evidence suggests that early interventions can provide long-term health and socioeconomic benefits by prevention of the onset of mental health problems and their development into chronic disorders...The situation in LMIC also presents a window of opportunity, because many LMIC are currently going through a demographic transition, and intervention today is likely to result in a decreased burden in the future."

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