Dossier n. 160/2007 [Abstract] Child and Adolescent Mental Health Policies and Plans

1. Context of child and adolescent mental health

Children and adolescents with good mental health are able to achieve and maintain optimal psychological and social functioning and well-being. They have a sense of identity and self-worth, sound family and peer relationships, an ability to be productive and to learn, and a capacity to tackle developmental challenges and use cultural resources to maximize growth. Moreover, the good mental health of children and adolescents is crucial for their active social and economic participation.

This module demonstrates the need to promote the development of all children and adolescents, whether or not they have mental health problems. In addition, it is important to provide effective interventions and support to the 20% of children and adolescents believed to be suffering from overt mental health problems or disorders. The burden associated with mental disorders in children and adolescents is considerable, and it is made worse by stigma and discrimination. In many situations, mental disorders are poorly understood, and affected children are mistakenly viewed as “not trying hard enough” or as troublemakers.

There are three compelling reasons for developing effective interventions for children and adolescents: (i) since specific mental disorders occur at certain stages of child and adolescent development, screening programmes and interventions for such disorders can be targeted to the stage at which they are most likely to appear; (ii) since there is a high degree of continuity between child and adolescent disorders and those in adulthood, early intervention could prevent or reduce the likelihood of long-term impairment; and (iii) effective interventions reduce the burden of mental health disorders on the individual and the family, and they reduce the costs to health systems and communities.

The mental health of children and adolescents can be influenced by a variety of factors. Risk factors increase the probability of mental health problems, while protective factors moderate the effects of risk exposure. Policies, plans and specific interventions should be designed in a way that reduces risk factors and enhances protective factors.

2. Developing a child and adolescent mental health policy

Without guidance for developing child and adolescent mental health policies and plans there is the danger that systems of care will be fragmented, ineffective, expensive and inaccessible. Several different systems of care (e.g. education, welfare, health) may need to be involved to ensure that services for youth are effective. An overriding consideration is that the child’s development stage can influence his/her degree of vulnerability to disorders, how the disorder is expressed and how best treatment should be approached. Thus a developmental perspective is needed for an understanding of all mental disorders and for designing an appropriate mental health policy.

This section identifies the steps needed to develop a child and adolescent mental health policy. This policy may be part of an overall health policy, a child and adolescent health policy or a mental health policy. These are not mutually exclusive categories; indeed, more effective action is likely to result when the mental health of children and adolescents is addressed across all these policy dimensions.

Step 1: Gather information and data for policy development
The development of a child and adolescent mental health policy requires an understanding of the prevalence of mental health problems among children and adolescents. Their needs are inextricably linked with their developmental stages. It is also important to identify the existing financial and human resources available, the existing service organization, and the views and attitudes of health workers in addressing child and adolescent mental health issues.

Step 2: Gather evidence for effective strategies
Pilot projects can provide information about successful interventions as well as why certain programmes may have failed. When evaluating pilot projects and studies in the international literature, it is important to consider the distinctions between efficacy (an intervention’s ability to achieve a desired effect under highly controlled conditions) and effectiveness (an intervention’s ability to achieve a desired effect within the context of a larger, non-controlled setting). The findings from a study using a well defined population group under highly controlled conditions may not necessarily be replicable in a “real life” setting; therefore caution is needed in directly applying findings from clinical trials into real life settings without appropriate consideration to implementation issues. Nonetheless, there are a number of effectiveness studies using adequate methodology, the findings of which are strong enough to adopt on a broader scale. Policy-makers should hold consultations with colleagues and nongovernmental organizations (NGOs) from other districts, provinces, countries or regions when deciding upon the appropriateness of programme models that meet reasonable standards of effectiveness, for incorporation into policy.

Step 3: Undertake consultation and negotiation
While consensus building and negotiation are important at every stage of the policy planning cycle, effective policy-makers will use the initial information gathering as an opportunity to begin building consensus. There are three reasons why it is important to hold consultation with a wide range of stakeholders: (i) the social ecology of children and adolescents is such that their interests and needs should be met in a range of settings; (ii) a consultation process can increase the buy-in of crucial stakeholders; and (iii) involvement in a policy development process may increase stakeholders’ insights into the potential contributions of their sector to the mental health of children and adolescents.

Step 4: Exchange with other countries
International consultations can make an important contribution to policy development, especially when the consultants have experience in several other countries that are similar in terms of level of economic development, health system organization and governmental arrangements. National and international professional organizations can be instrumental in providing support and promoting networking. Both the headquarters and regional offices of the World Health Organization (WHO) can facilitate such exchanges with other countries.

Step 5: Develop the vision, values, principles and objectives of the policy
In this step, policy-makers develop the core of the policy, using the outputs of the first four steps. The vision usually sets high but realistic expectations for child and adolescent mental health, identifying what is desirable for a country or region. This would normally be associated with a number values and related principles, which would then form the basis of policy objectives. Many countries’ policy-makers believe it is important to address the promotion of healthy development and the prevention of illness along with the treatment of child and adolescent mental disorders, although the emphasis placed on each differs across countries.

Step 6: Determine areas for action
In developing a mental health policy for children and adolescents, policy-makers need to coordinate actions in several areas (listed below) to maximize the impact of any mental health policy.

• Financing
• Organization of services
• Promotion, prevention, treatment and rehabilitation
• Intersectoral collaboration
• Advocacy
• Legislation and human rights
• Human resources and training
• Quality improvement
• Information systems
• Research and evaluation of policies and services

Step 7: Identify the major roles and responsibilities of different stakeholders and sectors
It is essential that all stakeholders and sectors have a clear understanding of their responsibilities. All those who were involved in the consultation process could be considered.

3. Developing a child and adolescent mental health plan

Once the mental health policy has been completed, the next step is to develop a plan for its implementation. The development of such a plan builds on the process already established for policy development as outlined above. Information about a population’s needs, gathering evidence and building consensus are important in the formulation of such a plan. A plan consists of a series of strategies, which represent the lines of action that have the highest probability of achieving the policy objectives in a specific population.

Step 1: Determine the strategies and time frames
In developing and setting priorities for a set of strategies, it is often useful to conduct a SWOT analysis, in which the strengths, weaknesses, opportunities and threats of the current situation are identified. Following a SWOT analysis, a series of actions should be taken to develop and identify priorities for a set of strategies: (i) create a comprehensive list of potentially useful proposals for each of the areas of action developed during the policy formulation phase; (ii) brainstorm with key players to develop a set of strategies for implementing each of the proposals; (iii) revise and modify strategies based on a second round of inputs from key players so that there are two or three strategies for each area of action; (iv) establish a time frame for each strategy; and (v) develop details for how each strategy will be implemented. Details include setting indicators and targets, outlining the major activities, determining the costs, identifying available resources and creating a budget.

Step 2: Set indicators and targets
Each strategy should be accompanied by one or more targets which represent the desired outcome of the strategy. Indicators enable an assessment of the extent to which a target has been met.

Step 3: Determine the major activities
The next step should be to determine the actual activities that are necessary for each strategy. Each activity should be accompanied by a set of questions: Who is responsible? How long will it take? What are the outputs? What are the potential obstacles or delays that could inhibit the realization of each activity?

Step 4: Determine costs, available resources and the budget
The budget is the product of an assessment of costs in the context of available resources.

4. Implementation of child and adolescent mental health policies and plans

Step 1: Dissemination of the policy
Formulated policies must be disseminated to health district offices and other partner agencies, and, within those agencies, to individuals. The success of the dissemination of a policy, plan or programme will be maximized if children, adolescents and their families are reached at a variety of locations, such as schools, places of worship, streets, rural areas and workplaces.

Step 2: Generate political support and funding
No policy or plan, no matter how well conceived and well researched, has a chance of success without political support and a level of funding commensurate with its objectives. Because young people are often dependent on others to advocate on their behalf, advocates for child and adolescent mental health should seek to ensure the political and financial viability of a plan, independently of the persistent advocacy of the service users themselves. Advocates for mental health policy within a ministry of health will need to identify allies in other parts of the government, and in the community or country at large.

Step 3: Develop a supportive structure
The implementation of a child and adolescent mental health policy and plan requires the participation of a number of individuals with a wide range of expertise. Individuals with training or experience mainly applicable to adults may have to be assisted by other appropriate specialists to make planning applicable to children and adolescents.

Step 4: Set up pilot projects in demonstration areas
Pilot projects in demonstration areas, where policies and plans can be implemented relatively rapidly, can serve several useful functions: they can be evaluated more effectively and completely; they can provide empirical support for the initiative through their demonstration of both feasibility and short- and long-term efficacy; they can produce advocates from the ranks of those who participated in the demonstration area; and they can educate colleagues from the health and other sectors on how to develop policies, plans and programmes.

Step 5: Empower providers and maximize coordination
The chances of successful implementation of an intervention will be enhanced if service providers are sufficiently empowered and supported in terms of information, skills, ongoing support, and human and financial resources. A first step in this process is to identify which individuals, teams or organizations in the health or other sectors will be responsible for implementing the programme. All sectors have a stake in both the present and future physical and mental well-being of young people. Collaboration (including cost-sharing) around mental health initiatives produces win-win situations for everyone, most importantly for the young people involved. In addition to intersectoral collaboration, other stakeholders (such as officials in the areas of education and justice) need to interact on an ongoing basis to maintain support for and ensure the smooth delivery of mental health services.