(WP)MNH/ICP/PSF/OOl
ENGLISH ONLY
ReGIONAL WORKING GROUP ON CHILD MENTAL HEALTH
Convened by the
REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION
Singapore, 13-16 November 1985
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines April 1986
NOTE
The views expressed in this report are those of the members of the Regional Working Group on Child Mental Health and do not necessarily reflect the policies of the World Health Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Kegion and for the members of the Regional Working Group on Child Mental Health, held in Singapore from 13 to 16 November 1985.
COt'ITt:NTS
1. 'l..
IN fRODUC'f ION ........................................................................................ ..
1
SUptMRY OF MENTAL KEALTti PROGRAMMES OF WHO WESTERN PACIFIC REGIONA~ OFFICE ••••••.•••.•..•••••••••••••••••••• SUMMARY OF ACTlV UIES ON CHII.D MENTAL KEALTH OF WHO •.•••• IDENTIFICATION OF CHILD MENTAL iiEALTti PROBLEMS IN THE REGION ......................................................................................................
2 2 4
3. 4. S.
EXISTING AND POSSIBLE NEW MEASURES, SERVICES AND CARE ••.• EDUCATION AND 'fttAINING ................................... RESEAiCri TUND ...................................................................................... ttESEARCH. PROPOSALS .............................. ,...............................................
7 11 12 15
o. 7.. d.. 'J..
CONC1.USIONS.. .. .... .. .. .. .. .. .. .. .. .. ...... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
15
10.
Rl::COHMEHDATIONS. • • • •• ••• ••• • • . • • . . • . • . . . . . • • • • • • • • • . • • • • . OPENIN~ SPEECH OF DR H. NAKAJIMA REGIONAL DIRECTOR, WHO WESTERN PACIFIC REGION
16 19 21
ANNEX! ANNEX 2 ANNEX 3 AN1'IEX 4 -
LIST OF MEH8ERS, OBSERVERS AND SECRETARIAT .••••••••
TERKS OF REFt:RENCE •••••••••••••.••••••••••••••••••• 25/26 AGENDA ................................... "' ................................................ 27/28
ANNEX 5 ANNEX 6 ANNEX 7 -
LIST OF BACKGROUND DOCUMENTS ••••••••••••••.•••••••• 29/30 EDUCAT IOd PACKAGE ABOUT CHlLOREN' S MENTAL KEALTH NEEDS .................................................. .o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.o......
31
MU~TI-NATIONA~ COMPARISON OF CHILDREN'S BEHAVIOURAL PROBLEMS ......................................................................................
37
1•
INfROOUCTION
The ae~ional Working Group on Child Mental Kealth was convened from 13 to 16 November 1985 in Singapore in collaboration with the Ministry of Health, Singapore and the Singapore Association for Mental Kealth. Tne o~ening ceremony ,.,as held at the Aerides Room of Novotel Orchid Inn, Singapore. Dr Chen Ai Ju, Deputy Director, Medical Services, Primary Health Care and Health Education, Ministry of Health, Singapore, and Or Paul Ngui, ?cesident, Singapore Association for Mental Health, Singapore, delivered a welcome speech to the Group. Dr Wong Sze Tai, Head of Department, Child Psychiatric Clinic, Institute of Health, delivered a message on behalf of the local organizing conuittee.
Dr Naotaka Shintuku, Regional Adviser in Hental Health and Drug Dependence, delivered the opening speech on behal f of Dr Hiroshi Nakajima, ~egiona1 Director, who was unable to attend. In his message, the Regional Director expressed his sincere gratitude to the GovenUllent of Singapore for kindly agreeing to host the Regional Workin 6 Group. He noted th~t tne Fifth Asean Forum on Child and Adolescent Psychiatry would be held illllll8diately after the Working Group meeting, from 17 to 19 November 1985, with the participation of more than 400 experts in child mental health, and observed that these events would promote an awareness of the importance of the mental well-bein, of child and adolescents in the Region. The opening speech of the Regional Director is attached as Annex I. Dr John Orley, Senior Medical Officer, Division of Mental Health, world Health Organization, Geneva, participated in the Working Group and provided a global perspective of child mental health programmes to the Group. ~e6ion
The meeting was attended by eleven members from nlne countries in the and five observers from Singapore.
Dr Wong Sze Ta i, Singapore, was appo in ted Cha irman, Dr Kang-E Michael Hong, Kepublic of Korea, Vice-Chairman and Dr Woon Tai-Hwang. Malaysia, and Dr Odita Yatco, Philippines, as Rapporteurs. The list of members, observers and secretariat is attached as Annex 2. Tne terms of reference as well as the Agenda for the meeting are attacned as Annex 3 and Annex 4, respectively. Also, the list of background information is attached as Annex 5.
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2.
SUM..'iAR'l OF MENTAL il.EALTiI. PROGRAKMES OF WHO
Dr N. Shi'lfuku introduced the programmes on ..ental health of the World liealtn Orgallization usillg the slides. He drew the attention of members to the resolutioll on Mental Health (W~R/RC36.Rl7) adopted at the thirty-sixth sessioll of the Re 6 ional Committee for the Western Pacific in September 1985. The resolution, a,Qong others, requested the Regional Director to initiate, wherever possible, programmes dealing with issues of particular interest to countries in the Region, such as the promotion of child mental health and prevention of ~ental retardation and senile dementia.
:3.
SUM..'1ARY
OF
ACTIVITIES
ON THE
CHILD MENTAL HEALTH PROGRAMME OF WHO
The child melltal health progral1l11le of WHO gives attention not just to the prevention and treatment of psychiatric disorders but also to the broader issues of the mental life and psychosocial development of children. It is, of course, justified that the unacceptably high infant mortality rates in some populations should be the focus of international attention. Nevertheless, the majority of children do survive. and the quality of their life, particularly their mental life, also needs to be given the attention it deserves. Tne programme therefore concerns itself with~
(a)
promotion of the mental life and psychosocial develop~ent of all Children with particular emphasis on vulnerable population groups or individuals at ris~; attention to the pSyChological and social factors at play in the presentation of children at all health facilities, whether for physical or psyclliatric disorders; prevention, diagnosis and treatment of child psychiatric disorders. Previous work of WHO
(b)
(c) 3.1
Over the last decade, WHO has coordinated projects on a variety of topics in these fields. It has developed manuals on child mental health with special attention to developing country needs for primary health care workers, primary care physicians. teachers and workers in children's homes. It has brough t together research workers fro'Q developing countr ies ill a project in whicll sOllie of the child mental heal th needs presenting at pr illl8ry health ca["e lev~l were identi.fied and enumerated. This indicated a prevalence of such conditions of 13-18% in rural areas and 25-30% in urban areas. WHO has also coordinated the development of the multiaxial classification of childhood psychiatric disorders. In addition to these projects involving international collaboration, WHO has also provided consultants in child mental health to governments needing advice and help, and collaborated in organiz inc; national training progralTOlles and workshops on th is topic.
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3.2
Current programme of WHO
A set of criteria is being developed for the assessment of day care centres for normal children. In particular these criteria have been formulated to ensure that the day care centres pay due attention to the children's developmental needs. A draft set has been pr-oduced and piloted Ln ttlree widely different centres. They will now be tested for reliability in use and some measure of their validity will be obtained also. ~O is concerned not only with conditions in day care centres, however, but also with the optimal conditions obtainable in the home for tne good PSYCllosocial development of children. These are also being developed in widely different cultur-al settings and it is expected that they may vary considerably between countries and even between different sociodemographic groupings within countries. The aim is to identify Illeasuraole factors in the homes of, say, urban deprived groups, with a view to seeing which ones are associated with homes which, despite the poor external conditions, nevertheless seem to house children who are developing well. The hope is that such factors might be transferrable in some way to otner homes, in the ex~ctation of improv ing ch ild development in those also.
early stimulation progrllRll'Des, both in day care settings and nome-based, are being reviewed, with a view to their adaptation and application in widely different settings and their evaluation. It is recognized however that measures of child psychosocial davelopment are seldom standardized for the popuLation in which they are being applied, and indeed the items used may sometimes be culturally inappropriate. For this reason, the WHO Division of Mental Health is working with the Division of Family Healtn (Maternal and Child Health) to produce guidance on developing milestones of development, which can be used by primary health care workers for the assessment of psychosocial growth equivalent to providing them with weight and height charts for physical grow tn. Reviewa are also taking place of tne mental health implications of legislation concerning child welfare related to the care of children where, for one reason or another, parental care has become inadequate. The situation will be examined carefully in certain centres to see what legislation exists and how it is applied, and to note problem with its application. It is expected that this will enable WHO to produce guiding principles concerning the possible content of such legislation such that it can take account of the children's mental health needs. The current classification of child psychiatric disorders in International Classification of Diseases, 9th Edition (ICD 9) and the Multiaxial Classification (MAC) are being reviewed in preparation for International Classification of Diseases, 10th Edition (lCD 10). 3.3 Planned WHO activities not yet initiated
- Incorporation 0 f famil y and ch ild men ta 1 hea 1 th care in to pr imary health care, with evaluation of the \oIHO child mental health manuals. - Provision of extensive treatment within primary health care for children with epilepsy in developing countries.
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- Identification and assessment of children with sensory defects and with intellectual impairments. - Management of intellectually disabled children in the community. - Epidemiology of the psychosocial factors associated with accidents to children. - Programme to assist children and their families in high risk situations, e.g. refugee camps. - Introduction of a mental health component into health education provided in schools.
4.
IDENTIFICATION OF CHILD MENTAL HEALTH PROBLEMS IN THE WESTERN PACIFIC REGION
4.1
Introduction
The Western Pacific Region comprises a very diverse group of countries in terms of size, population, affluence and availability of child mental nealth services. Despite this diversity, it appears that it has many child mental health problems in common. While it is important to identify shared problems, it is equally important not to deny the substantial differences which exist. In considering regional child mental health problems, the Group did not restrict itself to a narrow diagnostic framework. Thus, the categories of problem listed below are not intended to be mutually exclusive. The most consistent theme to emerge in the country profiles is that countries are experiencing a time of rapid sociocultural and socioeconomic Change. Many of the problems identified are a consequence of how societies meet the challenges of these changes. In particular, many problems of adolescents are related to rapid Change. 4.2 A rapidly changing world
Countries live in a rapidly changing world with increasing industrialization, growing use of "labour-saving" technology, and a communicatiol1 explosion. This has led to greater expectations in terms of goods and services, increasing urbanization and high employment. In most countries the gulf between the rich and the poor continues to widen. All of these changes have had a serious impact on families and children. 4.2.1 (1)
Family pattern
Move toward nuclear families. In most societies there is a move away from the extended family structure. This has led to a breakdown in traditional family support systems and greater demands on parents to fulfil many roles. (2) Family breakdown. t~o-?O~~Qt fa.ily tnrough divorce ~riods vork~ng or seeklng work.
Most countries report increased disruption of the or absence of parents for extended There has been a parallel rise in
single-parent families.
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() Family size. With the concern expressed about population growth, tnere have been many highly successful family planning campaigns. This has meant tnat 1 - 2 cbild families are the norm. In these families, particularly single child families, great expectations are placed on children. These expectations are in terms of achievement, academic success, overprotection and often excessive control. (4) Substitute care. The lack of extended family support and the increase in two working parent families has created a need for other forms of child care. These vary from higb quality day care facilities to foster-care for preschool children and even child abandonment. The impact of different forms of child care on children is largely unknown. (5) Family dislocation. Families are much more mobile than previously owin& to urbanization and disasters, both man-made (wards) and natural (flood, fire, famine). For this has meant the need to adjust to a completely new way of life in the city or a foreign country. The impact on children of such moves is largely unknown. 4.2.2 Education
With the increasing competition for scarce resources, education is often seen as the pathway to affluence and success. (1) The pressure on children to succeed at school is increasing in many countries and the consequences of failure may include disillusionment, depression and suicide. (2) School failure, refusal and truanting - The increased emphasis on schooling has drawn attention to children with learning difficulties. 4.2.3 Antisocial behaviour
Most countries report increases in various forms of antisocial behaviour. Questioning of parental values and even violence towards authority figures, includin& parents and teachers, seem to be increasing. 4.3 Adolescents Problems among adolescents include~
(1) Drug and alcohol abuse - this seems to be increasing, its onset Decoming earlier. (2) Deliquency - antisocial acts a&ainst both persons and property are increasing. (3)
Teenage pregnancy and single motherhood High unemployment Hornelessness Depression and suicide
(4) (5) (6)
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4.4
Children with handicaps
There is an increased prevalence of "clinical maladjustment" in children with all forms of handicap, especially if this involves the central nervous system. ll) Physical. As acute infectious diseases are gradually controlled, increasLn¥ attention can be given to children suffering from various handicappin¥ disorders, including malnutrition, epilepsy and other chronic physical illnesses. (2) Int~llectual. Mental retardation continues to constitute one of the greatest predisposing factors to child mental health problems. It may be associated with epilepsy and other physical problems. (3) Emotional. Pervasive developmental disorders such as autism and childhood psychosis constitute a serious mental health problem. While relatively uncommon, they place disproportionate demands on scarce resources. 4.5 Child maltreatment
In recent years increased attention has focused on various forms of cnild maltreatment in developed countries. The frequency in developing countries is largely unknown. The spectrum of maltreatment includes~ (1) (2) (3) Physical abuse, including infanticide. Sexual abuse, including incest and rape. Emotional abuse - problems of definition are marked.
(4) Exploitation - this includes experiences as diverse as depriving children of schooling to do domeatic duties, premature use of children Ln the workforce and child prostitution and pornography. (5) Abandonment - some countries report high rates of abandoned children, who then require foster placement or institutional care. 4.6 Minority groups
Some countries in the Region have significant indigenous minorities wno have been disenfranchised. Children in these groups are often characterized by particularly high rates of the problems listed under adolescents. These children are also particularly prone to failure. 4.7 Poverty
Many children in the Re~ion are still affected by marked poverty. This lIas many detrimental consequences including malnutrition, poor health care, inadequate educational opportunities, exploitation and abandonment, which may lead to behavioural and developmental difficulties.
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4.8
Af fluence
This is clearly only a problem in some countries or among some groups in a country. The greater expectations of material goods and the changing family patterns referred to earlier pose new and unanticipated mental health problems for the children of the future.
S.
EXISTING AND PO$SIBLE NEW
~EASURES
FOR ALLEVIATING
CIULD MENTAL KEALrH PROBLEMS
5.1
Introduction
Although there is considerable diversity within the Region regarding the manner and de,ree to which child mental health problems are currently being addressed, there are also areas of common concern and aspiration. Even in the more developed countries, considerable changes are needed and additional resources and manpower required, as well as creative solutions to eloergent problems which have not yet been addressed, such as those of children of cultural minorities, dislocated families, increasing numbers of blended families and single parent families, educational failure and others. The recommendations of the 1977 report of the WHO Expert Co~~ittee on Child Mental Health and Psychosocial Development makes recommendations on the prevention of childhood mental disorders and the fostering of healthy psychosocial development and on the treatment of mental disorders in children. When existing attitudes, policies and services are examined, these recommendations are found to be jus t as val id today as in 1977. Although there have been commendable changes in many countries, in most cases these represent only a beginning and not the attainment of even minimal standards of prevention, mental health promotion or care. 5 .2 Advocacy
All countries see the role or the mental health professional to include that of an advocate for the mental health needs of children. In this capacity, many are working to try to inform government bodies and policy makers regarding the mental health needs of children. This, in many Lnstances, is a slow and difficult process of education, modification of traditional attitudes, hindered in most instances by competition for scarce fiscal resources. Effective coordinating groups to oversee and ensure the rational development of child mental health services and to safeguard the mental health needs of children in all services have yet to be established in most countries. 5.3 Attitudes information
Changing of public and government attitudes is seen as being a crucial antecedent of significant change in the mental health status of children ~n the Region. Parents and extended family members, together with professionals and lay people working with and caring for children, need Lnfor~tion about Children's developmental needs and normal developmental
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processes, among other things, to help change some practices currently detrimental to children and which contribute to the development of mental disorder, such as, disrupting the continuity of the child's attachment to parents by separation, inadequate standards of child day care, attempted illegal abortion resulting in mental retardation, selective abortion of female foetuses and many others. 5.4 StilSma
Public attitudes toward mental health problems still result in some degree of stigma in all countries in the Region and affect people's readiness to seek help. This is a major area needing change. There is considerable concern about the need for confidentiality of personal information and case records relating to those children or families who do seek help. 5.5 Voluntary organizations and self-help groups
SOloe countries have seen the development of a large number of diverse voluntary organizations and self-help groups which provide support and assistance to children and families, particularly those with special needs. fhis assistance ranges from food and clothing, to day and residential treatment/educational facilities, and counselling services. Official acknowledgement of the role of such organizations is required with a supportive, facilitative and collaborative approach developing toward them by government bodies. Such organizations add to the diversity of cOlmnunity services and may have a flexibil ity to develop new approaches not available within larger formal institutions. 5.6 Family planning and preparation for parenthood
Host countries in the Region now have developed effective family planning programmes, which have resulted in an overall decline in birth rates. There is still concern in sorne countries, however, about the birth of unwanted children and for the welfare of children born to young unwed mothers. In tne more developed countries. this group of children (and their mothers) is receiving additional attention and support. These countries are also giving positive atte.ni.on to preparation for parenthood and extending educational endeavours from the well-established ante-natal prograllllues for parents to the education of chi1.dren and adolescents in schools about child development, interpersonal relationships, social ski1.1s, and sex education. Evaluation of the impact of such programmes is required. 5.7 Developmental health surveillance
Ongoing information for parents on child rearing is being encouraged in the more developed countries. Altilough some of the deve1.oping countries also have well-baby clini.cs, some of the staff tend not to be well educated i.n the mental health needs of children and families. This opportunity to promote healthy development of parent-child relationships, to detect and intervene at an early stage in behavioural and emotional problems is not therefore being fully utilized. Even in the more developed countries, there is room for improvement in the mental health skills of well-baby
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clinic staff and the number of personnel per child population. Routine, and regular developmental health care of all children remains a goal to be pursued. Emphasis is required on the i~port3nce of early detection and intervention for a variety of developmental delays and disorders and benavioural disturbances. 5.8 Supportive services
Throughout the Region, there have been significant changes in family structure in recent years with a pervasive movement toward nuclearization, and a marked increase in single parent families in many countries. The need for supportive services to nuclear families which will facilitate their ability to provide a secure nurturing environment for their children seems to be acknowled&ed by most countries, but the present availability of such support i. very varied and often of questionable quality. 5.9 Day care
Good quality day care, within the extended family, within selected and supervised family settings and within day care centres with appropriately trained adequate staff, and adequate play facilities, is still urgently needed in most countries. Parents also need information as to how to use day care constructively for the benefit of child and family. 5.10 Economic assistance
Economic assistance to low income families with young children is an issue which is being addressed only in the more developed countries. 5.11 Surrogate care
Surrogate care of children is a matter of concern for differing reasons in most countries. In some, the indiscriminate placement of children in foster care for the convenience of parents is having a significant detrimental impact on child mental health. In others, the concern is the availability of good quality foster care for children who have been abused, neglected, abandoned or who for other reasons cannot live with their natural families. In all countries, there is still concern about the nature and size of many residential institutions for children and their inability to meet the Children's needs for normal psychological development. 5.12 Legislation
Cnanges in legislation which will facilitate the permanent placement or adoption of young children who cannot return to their natural families are still required in most countries. For those for whom adoption may not be appropriate or possible but who require permanency (e.g. older children and adolescents), legal safeguards (e.g. guardianship) are needed for the relationship between child and foster parents and, in some instances, financial assistance to the foster family.
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5.13
Community mental health services
While there has been a significant develo~~ent of community health services in recent years in a number of countries, the mental health needs of ch~ldren or families are not well catered for within these services at present. There is a need for a higher level of awareness and mental health skills among primary health care personnel, including many family medical practitioners and paediatricians. The value of behavioural paediatrics in community health services is acknowledged as well as the need for more specialized child psychiatric consultation, not only to families, but also as a back-up resource to primary healtn care personnel. The availability of counselling services is central to the provision of community mental health services and workers require skills in counselling children or families. Hental health promotion and education are also pri.uary objecti.ves of such servicl!s, and need development or expansion in moat countries. 5.14 Other services
The mental health components of educational and welfare services are acknowledged and additional advisory and counselling personnel in schools is encouraged. 5.15 Child psychiatry services
Tnere is now a specialist child psycniatry presence in some countries in the Western Pacific &egion. In some, this development is quite recent and manpower and resources limited. However, there are still a significant number of countries with no child psychiatry services. Not even in the developed countries do the numbers of trained personnel approach internationally recommended levels on a population basis (e.g. one child ~sychiatrist and multidisciplinary team per 20 000 child population). The range of services available is variable, even in the developed countries. It is accepted that there is a need for outpatient, daypatient and inpatient (both acute and long-term) facilities for the management of child psychiatric disorders and a range of additional facilities, e.g. group homes, hostels, half-way houses, particularly for adolescents. The develo~ent of psychiatric facilities and the necessary staff skills to provide treatment for the child's family as a functional uni t is encouraged. 5.20 Distribution of resources
In some countries, child psychiatric services are available within both the public and private sector. Private sector treatment is available only to the privileged few in most of these countries and in some countries there is some tension between the two settings. The advantages to the mental health professional of working in the private sector may lead to an imbalance in the distribution of resources between the two sectors.
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5.21
Distribution of resources
In all countries there is concern about the equitable distribution of resources to child mental health services. In no country at present does the allocation of resources reflect the importance of children as members of society nor the importance of child mental health to the well-being and health of the nation.
6.
TRAINING AND EDUCATION
There is a serious shortage of child mental health workers in all countries of the Western Pacific Region. Resources for child mental health services are ultimately best supplied by professionals trained in their own country and thus familiar with cultural variations within their country. The shortage of child mental health work~rs appears to be related to a low priority status for child mental health services, lack of knowledge about child mental health needs, financial constraints and lack of training programmes despite considerable cultural interest in their children. 6.1 Child psychiatry training
General psychiatry training needs to have six months' child training ~n all programmes. Training in child psychiatry for paediatricians and family physicians is very much needed but limited by the resources to provide this education. Training for child psychiatry varies in the different countries of the Region. All trainin~ in child psychiatry is done after training in general psychiatry. Most programmes which offer cnild psychiatry training are two-year programmes. A few countries have yet to develop child psychiatry training programmes. Clarification in child psychiatry is awarded by the Sub-Committee on the Fellowship Board of the Royal Australia and New Zealand College of Psychiatry (RANZCP) in Australia and New Zealand. This requires six years of training in total and hence discourages trainees - New Zealand currently has no trainees in child psychiatry. Formal subspeciality boards in child psychiatry are unique in the States - four years of general training and two years of child fellowship training is required to be board eligible. 6.2 Child mental health training in allied fields
l
Training for allied professional fields in child psychiatric nursing, social works in child mental health and clinical child psychology is highly variable. A few countries have academic programmes available. Most countries depend on in-service training opportunities. Some offer training in specific therapies such as child psycnotherapy and family therapy.
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rraining for teachers, school counsellors, special education teachers is generally organized by the educational ministries and may include some lectures in child mental health. 6.3 Child mental health education uay
care staff training progra~Qes are in the process of organization in several countries while other countries have staff development programmes l.n place through the governlDent. Training for lay volunteers is being d~veloped by several countries. fhis includes training in counselling by various voluntary organizations in general and specific areas. Seminars on wholesome child rearing for parents, parent surrogates, adolescents and housemaids have begun in a few areas. Also the development of trailling for telephone crisis lines workers is needed and has been initiated. There is a universal lack of sufficient training, indeed a lack of any training, in some countries for primary health care workers in child mental health.
7.
REVIEW OF RESEARCH TRENDS IN THE REGION
Overall, the extent and the kinds of research in the countries of the Region seem to reflect each country's current/social concerns and developmental levels of child mental health services, ranging from very few projects to an extensive number of projects completed or undergoing, from more general epidemiological studies to studies on more specific disorders. Topics of the research and some of the results will be summarized as follows according to major categories. 7.1 Epidemiological studies
Two different kinds of epidemiological studies are under way. One is an extensive survey of child lDental health problelDs at national level and the other is a survey of particular disorders or problems. Ch~na, Singapore and the Republic of Korea have conducted a behaviour problem survey on more than 1000 school aged children, using Achenbach's questionnaire. Other nationwide surveys using different questionnaires, such as a teacher questionnaire, were carried out in China, Republic of Korea and Singapore and the results indicate that prevalence of child mental health problems ranged frOID 5% to 20%.
Studies on more specific mental health problems or psychiatric disorders include psychopathology of children of alcoholic fathers (Australia), identification of vulnerability and prediction of psychiatric dLsorders among adolescents (Australia), prevalence of mental retardation (China, Republic of Korea), survey of street children (Philippines), juvenile delinquency (Japan, Malaysia, Republic of Korea), behaviour problems of three year olds (Singapore), psychiatric disorders of high school students (Republic of Korea) and others.
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7.2
AnalYli8 of clinic patient8
Some countrie8 (Philippine8, Republic of Korea, Singapore) reported a descriptive diagnostic analYlis of patients referred to child psychiatric clinics or p8ychiatric health care, which identified most of the psychiatric diagnoses reported in the western countries. Longitudinal studies of temperament (Australia and New Zealand) and premature children have been conducted. 7.3 Research on special topics of social concern
Among problems of great social concern, child abuse has received most attention in many countries (Au8tralia, Japan, Malaysia, New Zealand and Singapore) and it was agreed that child abuse has increased during the last decade, most probably because of changes in parenting attitudes, family oreakdown and single parent and other socio-cultural changes. However, demographic information about child abuse has not been available in some countries. In this connection, sexual abuse and sex violence (rape) seem to pose a particular problem in research (Australia, New Zealand and Republic of Korea) and need more exploration in future. Several studies are rightly concerned with the impact of parenting styles, different child care, fostering and day care (Singapore, New Zealand), and more attention should be paid in these areas, considering the rapid socio-cultural changes in all the countries of the Region. Special topics which have become important research subjects have been families living in remote areas (Australia), dislocated families (Australia, Japan, Republic of Korea and Singapore) and divorce (Australia, Japan and New Zealand). 7.4 Studies on specific psychiatric disorders
Most countries in the Region have carried out clinical studies on various psychiatric-mental disorders. Sleep disorders (Australia, New Zealand), chronic abdominal pain (Australia), attention deficit disorders (5% in China, 6% Republic of Korea), school refusal (in Japan, 40% of clinic sample, 0.01-0.4% school students), violence to parents and teachers (Japan), suicide (Japan, Malaysia, Singapore), drug abuse (Malaysia, Singapore), mental retardation (New Zealand, Singapore), autism (Japan, New Zealand, Republic of Korea), tic disorder (Republic of Korea), dyslexia (Japan, Republic of Korea), learning disorder (Japan, Republic of Korea, Singapore,), children with physical diseases (Australia, Japan) and neurosis (Republic of Korea, Singapore). 7.5 Adolescent studies
runong various studies on adolescents, delinquency, drug abuse, depression and suicide were the most frequent topics. While the suicide rate among adolescents seems to be rising in Singapore or other countries, it is declining in Japan. Some countries are concerned with teenage pregnancy (New Zealand and Philippines) and the implications on child rearin~ too. It seems that most countries have underreported the studies on ad~lescents in their country profiles.
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7.6
Studies on intervention
It is rather striking to note that research on interventions of mental health problems seems to be most inadequate and only a few projects were reported. Maternal-child health problems were described and studied in Japan and Malaysia. Care for mental retardation (Malaysia) and the day treatment progra~e for autistic children and the results were described in Republic of Korea. Family therapy for the families of infants and pre-schoolers with behavioural difficulties was described in New Zealand. 7.7 Standardization of diagnostic tools
While Australia, Japan and New Zealand have standardized most intellectual testing instruments for young and older children and adolescents, some countries like China, Philippines and Republic of Korea have limited diagnostic tools for preschool children and have to rely on softer screening tools like the Denver Development Screening Test (DDST) and Vineland Social Maturity Scale. 7.S General comments In reviewing the above research going on in the Region, the following comments can be made.
~eneral
(1) (2)
Most countries are currently undertakin~ a moderate amount of research in relation to child mental health. Many countries are conducting some epidemiological studies and the metho~ology and focus of the study need to be improved. Perhaps cross-national collaborative projects utilizing the same method might De desirable in future. In diagnosis and analysis of clinic population, most countries are DSM-III but some are using ICD-9 and a cross-national comparison might be ratner difficult. usin~
(j)
(4)
Al though most countries within the Region are concerned about rapid social changes such as nuclear family system, reduction of number of children, education stress, improving standard of living, not many studies actually address the etiological link between these changes and the mental health problems of ch ildren and adolescents. Research on intervention, particularly preventive, and early intervention is grossly lacking. There seem to be an urgent need in some coulltries to standardize dia&nostic instruments, especially for preschool age children.
(5)
(t»
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8.
RESEARCH PROPOSALS
Two research proposals were selected and discussed by the Working Group for possible WHO research proj~cts on child mental health in the Region, namely~ (1) (2) Education package about children's mental health needs. Multinational comparison of children's behavioural problems. The draft research protocol are shown as Annex 6 and Annex 7.
9.
CONCLUSIONS
The WHO Regional Committee for the Western Pacific, meeting in 1985, passed a resolution urging Member States to give increased attention to programmes designed to LDprove mental health and initiate programmes of particular interest to countries in the Region. The Committee singled out for particular mention child mental health among a few such programmes. It was therefore appropriate that WHO should convene this Regional Working Group, the first to be held on child mental health. The purpose of this meeting was to give guidance on how the Regiona 1 Of fice could bes t res pond to the child mental health needs of Member States. To this end, a variety of needs and problems were identified, the existing services and training facilities which could answer these needs were described and current research in this area was discussed. This led to an identification of possible new activities that could be initiated to improve child mental health care in the Region and to the formulation of specific proposals for projects. Tne problelUS facing the Member States were seen to include changes in family patterns through divorce, smaller size and other factors; undue pressure for educational success; antisocial behaviour and developmental problems in children; and the abuse and neglect of children. There is no doubt however, that there is a lack of knowledge among many of tne decision makers in countries as well as among parents and the general public, about the sorts of influence that lead to good development of children. The mental life of children is often only valued in terms of lmprovlng children's cognitive development, with undue emphasis on formal education and little concern given to the needs of pre-school children unless it is to encourage them to learn to read or write at a very early age. The Working Group therefore was most concerned with how to encourage a greater emphasis on children's development in Member States, a development involving not just physical growth but psychological and social growth as well, so that small children should be viewed as whole people. In addition to this attention given to mental development, the Working Group was concerned that the skills necessary for the prevention and treatment of child mental disorders should be more widely disseminated. Tllis would involve better training of child mental health ;>rofessionals, more training in the field for other workers in health and other sectors, and the development of technologies to help such workers identify problems both in research and in clinical practice.
- 16 -
It was recognized that resources are scarce and that intercountry collaboratioLl can make best use of the expertise available. It was also recognized that the resources of nongovernmental organizations, self-help groups and mechanisms whereby co~unities can participate in responding to needs, are valuable mechanisms for improving child mental health care. Research therefore has to aim at finding ways of raising national awareness of these issues, increasing community involvement in child mental health programmes, and developing technologies enablin6 all those providing services for children in whatever sector to become aware of problems at an early stage and to be able to respond to them.
10.
RECOKMENDA!IONS
(1) WHO should draw the attention of the Member States to the magnitude of the problems and increasing trends of various child mental health problems and the importance of developing programmes to promote good child mental health in the Region.
(2) There is a severe Shortage of personnel with skills in the child mental health areas. This applies both to child mental health professionals and to primary health care workers. The reasons for this manpower shortage include scarcity of resources and a scarcity of training opportunities. WHO should urge Kember States to give greater emphasis to the child mental health component in the training of all professionals who work with children at different levels, including~ (a) (b) (c) child psychiatrists and general psychiatrists with child psychiatric knowledge and skills; health workers and physicians involved 1n the prevention and delivery of primary health care; those engaged in school counselling and guidance services, police, social and cnild care workers.
(3) WHO should consider promoting workshvps or training programmes at regional and national levels, ai~d at expediting the components of Recommendation No.2. (4) WHO should urge each government in the Region to consider establishing a formal body to monitor the needs and well-being of children in their society and to advise government and other bodies on these matters. (5) WHO should emphasize the importance of early detection and intervention for developmental, emotional and behavioural disorders in children and adolescents. (0) WHO should urge Member ~tates to include mental health knowledge and skills in the elementary (primary health education) and high school curricula.
- 17/18 -
(7) Research activities on child mental health should be encouraged, including national (and cross-national) epidemivlogical studies, standardization ~f diagnostic categories and diagnostic tools, and evaluation of promotional activities for child mental health. (8) As immediate public education and research activities, the following cwo research proposals should be initiated;
(i) (ii)
preparation of education packages about children's mental health needs, and multinational comparison of children's behavioural problems.
- 1'J -
ANNEX 1 OPgNING ~PEECn OF DK rio NAKAJIMA REGIONAL DIRECTOR, WHO WgSTERN PACIFIC REGION Distinguished guests, dear colleagues, friends, ladies and gentlemen, It gives me great pleasure to say a few words on behalf of Dr Hiroshi Nakajima, Regional Director of the WHO Regional Office for the Western Pacific, at this opening of the Regional Working Group on Child Mental Health, wnicn is being held here from 13 to 16 November 1985. First of all, I should like to express my sincere gratitude to the Government of Singapore for kindly agre~in& to host this Regional Working Group. I am very glad to note that a number of officers from the Ministry ot nealth are attending the opening, which clearly testifies to the Lmportance accorded by the Government to tne child mental nealth programme. 1 note also that the Fifth Asean Forum on Child and Adolescent Psychiatry will be held nere illllllediately after the Working Group meeting from 17 to 1'J November 1985, with the participation of more than 200 experts in child meatal health. 1 am sure that these events will promote an awareness of the lmportance of the mental well-being of children and adolescents in the Region. Tne subject belng discussed at the ~orking Group is of great relevance for tne future health of the people in the Western Pacific Region and has direct implicatlons for the achievement of the goal of Health for All by tne Year 2000, to wnich the World Health Organization is directing all its efforts. As you may be aware, the Constitution of the World Healtn Organization defines healtn as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Child mental health is an area of growing concern in the countries/areas of the Western Pacific. The thirty-sixth session of the Regional Committee held in Manila in September this year adopted a resolution on mental health urging the Regional Director, wherever possible, to initiate programmes dealing with issues of particular interest to countries in the Region, sucb as the prolDotion of child mental health and the prevention of mental retardation. One of tne characteristlcs of the countries/areas of the Western Pacific Region is their diversity in size. The Western Pacific Regional Office (WPRO) serves the most populous and perhaps the most diverse of the world Healtn Organization's six Regions. Countries range in population over one billion in China to as few as 5000 in small island countries. In levels of development countries range from advanced industrialized countries to two of the world's least developed countries. However, there is one common feature - that most of the countries/areas are undergoing rapid socio-economic and cultural changes which affect the most sensitive and vulnerable population - cbildren.
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Annex 1 Child abuse and child neglect hav~ become serious social and health problems in the countries where the traditional concepts of the family have b~en challenged. Various behavioural disorders of children, such as delin4uency, violence at school and in the home, and childhood neuroses nave been reported to be on the rise in many newly industrialized countries where children are under pressure to compete and achieve. In poorer countries, unhealthy living conditions are retarding normal child development. Kental handicap is still an important but unrecognized health and social problem. Little is done about the plight of the mentally handicapped and their families and communities in many countries, »articularly developing countries, in the ;Re&ion. Kecognizing this situation, the WHO Regional Office for the Western Paciiic has launched a nu~er of activities related to child mental health in recent years. In November 1981, WHO collaborated witil the Government of the People's depublic of China in organizing a National Seminar on Child )iental Health in NanJing to discuss the development of child mental health programme in China. Support has been extended for studies on the mental health of schoolchildren in relation to their environment in Shanghai and Singapore. I am sure that the outcome of these studies will be described during the meeting. A working group on mental retardation was convened in Hanila in February 1985 with the participation of 13 leading experts and made relevant recommendations on developing programmes on mental retardation in the Region. As you will note, WHO programmes on child mental healtll are still at the embryonic or of very early stage in the Region. Tois working group, in fact, is the first regional meeting on child mental health. You are therefore asked to formulate recommendations on ways and means of developing the regional programmes. Your reco~~endations should include all the aspects of child mental health programmes, including prevention, the develo~ment of services, education and training, coordination with other sectors such as education and social welfare and technical cooperation between countries with and without the resources required. You are also asked to formulate realistic protocols for research on the most urgent problems of child mental health in the Region, research which can be carried out jointly by a few countries/areas. As you are leading experts in child mental health, I am sure that your contributions will be most valuable. I trust that your recommendations will be brought to the attention of the participants in the Fifth Asean Forum on Child and Adolescent Psychiatry, so that they will have a bigger impact. In conclusion, I should like to extend my thanks for the contributions or the many persons who have enabled the holding of this working group 1n Singapore. Special thanks are due to the me~ers of the Singapore Psychiatric Association. I wish you all successful and fruitful discussion and a pleasant stay 1n this charming city.
- 21 ANNEX 2 PROVISIONAL LIST OF MEMBERS, OBSERVERS AND SECRETARIAr 1.
ME:otIlEKS
Professor Robert G. Adler Director Departl1lent of Ch iid and Fal1lily Psychiatry Roya 1 Children's Hospital Flemin~ton Road, ~eIbourne Australia Dr Pushpa Bose Senior Registrar Child Psychiatric Clinic Institute of Helth 226 Outram Road Singapore 0316 Dr Yoshiko Ikeda Director Division of Child Mental Health National Institute of Mental Health 1-7-3 Konodai, Ichikawa Chibaken. Japan Dr Kang-E Michael Hong Associate Professor and Director Division of Child and Adolescent Psychiatry College of Medicine Seoul National University 28 Yungundon, Chongroku Seoul Republic of Korea Professor Toyohisa Murata Departl1lent of Psychiatry Fukuoka University Hospital Nanakuma, Jonan-ku 814-01 Japan Dr Elva Poznanski Professor Rush Medical Colleg~ and Senior Attending Rush Presbyterian St Luke's Medical Center 1720 West Polk Street Chicago, Illinois 60612 United States of America
- 22 Annex 2 Dr Wong Sze Ta i Consultant Psychiatrist and Head of Department Child Psychiatric Clinic Institute of HeaLtn 226 Outram Road Singapore 0316 Dr Woon Tai-Hwang Professor and Head Department of Psycholo 6 ical Medicine Faculty of Medicine University of Malaya Kuala Lumpur 22-1L Malaysia Dr Odita Yatco Associate Professor Department of Psychiatry university of the Philippines College of Medicine Taft Avenue Manila Philippines Professor Xu Taoyuan Director Uepartment of Psychiatry Shanghai Medical University 600 Wan Ping Nan Road Shanghai 200030 People's Republic of China Dr Karen Zeias Child Psychiatrist/Director Child and Family Guidance Centre Canterbury Hospital Board Private Bag Christchurch New Zealand 2. OBSERVERS
or Kwa Soon Bee Permanent Secretary Ministry of Heath Singpore Sivakami Dev i Director of Medical Services PHC 6. HE Ministry of Health Singapore Dr D~puty
- 23 -
Annex 2 Dr Chen Ai Ju Director Research and Evaluation Ministry of Health Singapore Ur Luisa Lee Associate Director Health Education Ministry of Health Singapore Dr Lam Sian Lian Medical Director Maternal and Child Health Services Ministry of Health Singapore Mr Goh Kim Leong Permanent Secretary Ministry of Educatio~ Singapore Mr John Yip Director of School Ministry of Education Singapore Dr Sim Wong Kooi Director Inatitute of Education Ministry of Education Singapore Mr Wong Hung Khim Permanent Secretary Ministry of Con~unity Development Singapore Dr Tsoi Wing Foo President Singpore psychiatric Association Singapore Dr Paul Ngui President Singapore Association for Mental Health Singapore
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Annex 2 3.
SECREfARIAT
Dr J. Orley Senior Hedical Officer Division of Hental Health World Health Or~anization Geneva Or N. Shinfuku (Operational Officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila Philippines
- 25/26 -
ANNEX 3
TERMS OF REFERENCr:
(1)
To review the activities on magnitude and those related
development of WHO-supported and other research child ~ental health in the Region, and to determine the nature of child mental health problems, particularly to rapid sociocultural change, and trends therein~
(1)
On the basis of the review, to discuss toe research results and their appLication in the context of primary health care and the organization of health services for Kealth for All by the Year 2000; To draw up plans and protocols for future research activities on child mental health, particularly proposals for thorough studies arising out of the preliminary results of the present study; To fonnulate recommendations to the Regional Director on the development of the programmes on child mental health in the Region.
(3)
(4)
- 27/28 -
ANNEX 4
AGENDA
1. 2. 3. 4. S. 6. 7. 8. ~.
Opening ceremony Guidelines for the meeting Presentation of country profiles Summary discussion on country profiles Proposal and selection of topics for further research and studies on child mental health in the Region Small-group workshops Other business Formulation of recommendations Review of the draft report Closing ceremony
10.
- 29/30 -
AN~EX
5
LIST OF BACKGROUND DOCUMENTS
1.
cnildhood Mental Disorders in Primary Health Care: Results of Observations in Four Developing Countries (A report from the WHO Collaborative Study on Strategies for Extending Mental Health Care) Child Mental Health and Psychosocial Development - Report of a WHO Expert Committee (Technical Report Series 613) Report - Second Regional Coordinating Group Meeting on the Mental Health Programme, Manila, Philippines, 25-31 October 1983 Report - Meeting of Heads of WHO Collaborating Centres in Mental Health, Tokyo, Japan, 1-4 October 1984 Report - Working Group on Hental Retardation, Kanila, Philippines, 18-22 FeDruary 1985 Information Booklet on WHO Supported Health Research wHO Regional Office for the Western Pacific Application for Financial Support for Health Research
~.
3. 4. 5. 6. 7.
- 31 ANNEX 6 EDUCATION PACKAGE ABOUT CHILDREN'S MENTAL HEALTH NEEDS 1.1 Introduction
c~ponent. f~r all by
Tne division of child health into its physical and mental health is both artificial and potentially counterproductive. "Kealth the year 2000" implies a holistic approach. Ignorance about cnildren's mental health needs i. widespread. Children are sometimes treated like miniature adults and at ti~es almost as though they do not exist prior to school age. There is frequently a failure to recognize the changes in physical, intellectual and em~tional development which occur throughout childhood. The first five or six years are of particular i'Dportance because of their formative r~le and the rapidity of development in those years. Therefore the first step towards promoting child mental healtll is education of all levels of sociaty about the mental health needs of children, particularly preschool children. This is not to imply that the needs of older children are unimportant. Nor is it to suggest that problems arising in the early years cannot be appropriately and effectively treated.
A great deal of information about child mental health and psychosocial development is already available. It is encompassed in documents such as tne United Nations Declaration of the Rights of the Child (1959 and 1973) and WHO Technical Report Series 613 (1977) as well as innumerable textbooks. Despite this wealth of knowledge, most of it is not in a form which is suitable or available to the majority of the society. Therefore there is a need to develop educational programmes which can be directed at specific groups within society. Such programmes must take local resources and the sociocultural values of the society concerned into account. WHO has an important role to play in helping child mental health yrofessionals prepare such packages so tnat they can then act as advocates for children within their societies. Such help should take the form of preparing the fralQewurk for educati~nal guidelines aimed at different 6rouPS. These frameworks need to be flexible enough to allow of their use ill different societies. Once such programmes have been implemented, their effectiveness should be evaluated in terms of changes in child welfare legislation, the development of child mental health services and studies on the ~revalence of child mental health problems. Specific programmes need to be developed aimed at the different levels of society groups to be addressed, including government, child mental nealth professionals, other pro~ssionals and caretakers, the general public, parents, children and adolescents. ~ome topics which might be included in the programmes for each group are outlined in 1.3. These are only intended as guidelines for the working groups which will be formed if sta 6e 1 of tne proposal is implemented.
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Annex b 1.2 Proposed ti.m.!table for implementation
to receiving WHO endorsement, members will be asked to form groups in their own countries to draft the guidelines aimed at each level of society. ueadline for completion of the fi.rst draft and forwarding to the WHO Regional Adviser in Hental Health in ~nila is 30 June 1986. The Regional Office will then be requested to circulate the drafts to ali members of the Working Group for comment. Comnents are to be returned to the author by 30 Septeuer 1986. The drafting group will then revise the draft for completion by 31 December 1986. The following are suggested convenors for the drafting groups for each sessiull~
~ubject
(a) (D)
Goverrunent - Or K. Zelas (New Zealand) Child mental health professionals - Dr R. Adler (Australia) Other professionals and caretakers - Dr T. Woon (Malaysia) General public - Dr R. Adler (Australia) in collaboration with Dr Ikeda (Japan) Parents - Dr P. Bose (Singapore) Children and adolescents - Dr O. Yatco (Philippines)
(c) (d) (e) (f)
As Dr Adler and Dr Zelas have agreed to act as joint co-ordinators for the project, members are requested to forward all correspondence to both co-ordinators. ~tage
2
(1~87-1988)
Tne second stage of the project involves WHO's promoting the educational packages available for government and child mental health ~rofessi.onals, to be used at their discretion. The guidelines are intended for use in the development of specific educational packages aimed at selected po~ulations in their own countri.es. Some countries may need to seek WHO's support in order to develop the specific package. Stage 3 (1989~ackages.
)
Tne thlrd sta 6 e involves the implementation and evaluation of these Many criteria of outcome can be defined. These include~
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Annex 6 ( i)
Acceptance of package in different countries. Introduction of new child w~lfare
(ii) ( iii) (iv) (v)
legislation.
Introduction of new child mental health services. Research funding for cnild mental health research. Data on child mental health problems.
1.3
Suggested guidelines for education packages about children's mental health needs
The following sections outline topics which could be included in the pr06rammes aimed at different groups in society: 1.3.1
Government
(1) Should be aware of long-te~ sequelae of inadequate psychosocial care which are enormous, such as the following: - abandoned ne61ected children - brain-dama&ed children phys~cally
damaged children
- mentally retarded children - juvenile and adult crime against property and persons - institutional care of offenders in correctional institutions and pr isons. (2) Comparative study on prevalence of above problems in other countries (to be done by respective countries). (3) Increased government awareness of child mental health elements 1n various government services for children and adolescents.
(4) Support to voluntary services and self-help groups in providing cost-effective and innovative easily accessible services. (5) Balanced approach by the government when the right of parents is 1n conflict with the Child's right for protection. (0) Need for government participation in the formation of children's commission to coordinate the various services for children.
(7) Need to look at and modify, if necess~ry, the existing legislation for protection of children and to formulate such laws if there are none exis t ing.
- 34 -
Annex 6 1.3.2
Child mental health professionals
(1) To include the following; child psychiatrists, social workers, psychologists, psychotherapists, guidance counsellors, psychiatric nurses and developmentally oriented paediatricians. (2) Should function as; advocates for cnildren to the following groups; government; professionals who have regular dealings with children including teachers, child care workers, lawyers ill famity and juvenile courts; ~arent~; public; and otller or~anizations like the police and religious groups. 1.3.3 (1) Other professionals and caretakers Other professionals to include the following;
- teachers/preschool teachers, paediatric nurses, public-health nurses, pollce, paediatricians, general practitioners, primary health workers, probation officers, welfare workers and others. - caretakers such as the following; day care workers, family group home staff, foster parents, house parents, child care workers, "nursemaids" and others. (2) Tne above groups to function as educators and implementors putting emphasis on the following. (i) (ii) (iii) (iv) (v) (vi) (vii) (v~ii)
why the first 5-6 years of life are significant to future development; educational approach using the developmental framework in physical and psychosocial development of the child; obligation of society to provide protection and care for its children who will become the future adult citizens; understanding of the different functions of the family; understanding of the child's growth and behaviour in his Psyc'losocial context, e.g. home, school snd institution; care of children outside the family, as, for example, in day care, foster homes, residential centres need special attention; the Child's spiritual development and freedom of worship; child abuse and neglect in homes and institutions; legislative responsibilities of the State and guardians of children when parents' interest comes in conflict with child's safety and survival.
(ix)
- 35/36 -
Annex 6 1.3.4 General public
(1) Educational package very si.ilar to those for other professionals and caretakers.
(2) (3)
Have individual and group responsibility to meet the child's needs. Must be educated on the legislation on child protection. Parents
1.3.)
(1) To include the following points of access~ adolescence, pre-natal, post-natal group such as pre-school and school group.
(2)
Areas to be covered are the (i)
following~
education ahout the realities of parenting using the develop3ental approachj normal developmental milestones, deviations, common problems and early indication of maladjustments; information on when and where help can be obtained; encouragement of parents to form and join self-help and support groups, e.g. play Kroups; father's active involvement in parentingj use of available cOmRunity resources for health check-up.
(ii)
( iii)
(iv) (v) (v i)
1.3.6
Children and adolescents Educational programmes on~
- "Keeping ourselves safe", such as being able to say NO; move away and tell someone about potential undesirable incident. - Comprehensive health educatLon to include mental health and psycho-sexual development. - Development or social skills and problem solving. - Coping with stress.
- 37 ANNEX 7 MULTI-NATIuNAL COMPARISON OF CKILD~N'S 8EKAVIOURAL PROBLEMS (~hina, Japan, Republic of Korea, Singapore and U.S.A.) Statement on the evolution of the project
i.
It is noted that currently three countries (China, Republic of Korea and Singapore) have carried out rather e~tensive behavioural surveys on primary schoolchildren, using Achenoach's CBCL. Japan is also interested in doing similar research, as is USA (Dr Poznanski). The centres which conducted this research expressed their problem in applying the instrument and interpreting the results and raised the hope of a cross-national comparison of the results. It became also clear that Achenbach's questionnaire may be too long to be utilized as a screening or diagnostic instrument in the Region; it may therefore be necessary to look at the possibility of and the need for developing a more suitable and shorter form of questionnaire according to the results of the cross-national comparisons. 2. Participating countries and investigators China, Dr Xu Japan, Dr Murata Republic of Korea, Dr Hot1 6 Singapore, Dr Wong (Coordinator) USA, Dr PoznansKi 3. Current status of the projects
China has already collected data from primary and junior high school students (7-16 years old) and clinic samples will be studied where the diagnosis will be based on DSM-III. Singapore has collected data from 3000 second 6raders and clinic patients and lCD-9 was used for diagnosis. The Republic of Korea has finished the collection of data from 2400 primary schoolchildren (7-12 years old) and 200 clinic patients and DSH-III was used for diagnosis. 4. (a) Objectives of the projects Define child mental health status in children of the Region and provide information on behavioural profile according to the Achenbach 4uestionnaire. Investigate cultural underpinnings of the differences, if any, or common behavioural problems of the children in the Region by conducting cross-national comparisons. Test the usefulness (validity and reliability) of the Achenbach questionnaire in its application to children in the Region and consider the development of a short screening instrument with fewer essential items.
(b)
(c)
- 38 -
Annex 7 5.
Plans and steps to be taken Instrument - Achenbach CaCL will be used in its e)(act form. Variables looked (i) (i i) at~
(a) (b)
(iii) (iv) (v)
(vi) (v ii)
(viii) (ix) (c)
ase 7-12 years old lQ over 70 according to group IQ test race religion socioeconomic class (use of the classification of international study of schi~ophrenia or according to occupation and education ot the head of the household). number of sibs living to~ether single vs two parents nuclear vs extended family others
Japan and Sin6apore will collect data from primary school students, at least 300-400 from each grade. Also more than 200 clinic samples will be recruited in Japan and USA. This data collection will be done independently on their own budgets. Global ~aladaptation
(d) (e)
scale will be done on all clinic samples.
When each centre has collected preliminary data, the investigators and consulting statisticians from all centres will get together in a worKin~ conf~rence.
(f)
All the data are pooled and sent to eitner Dr Achenbach or Dr Poznanski for cross-national comparison and factor analysis. Co-investigators to hold another workins conference (spring of 1986) to analyse and interpret the results, and to discuss the future projects such as follow-up studies, revising and/or developing shorter form of screening instrument. Toe results are to be published as a monograph or in journals.
(g)
(n)