Sustainable child and adolescent psychiatry

There is a growing public health crisis as increasing numbers of children and adolescents are facing the challenges associated with mental disorders. It is estimated that one in four children, either currently or at some point during their lifetime, will experience a mental disorder and in fact, half of all lifetime cases of mental illness begin by age 14 years (Kieling et al., 2011; Merikangas et al., 2009). Furthermore, globally, one-quarter of disability-adjusted life years (DALYs) for mental and substance use disorder occurs in youth (Global Burden of Disease Collaborative Network, 2017).

Along with COVID-19 and other social and political crises, it appears that the prevalence of these mental disorders in children and adolescents is growing. At the same time, the desperate shortage in mental health service providers leads to a situation in which children and adolescents do not receive care they need. The need for child and adolescent psychiatrists is especially critical in the context of modern adversities and inequities that profoundly affect youths’ mental health. Children and adolescents from less advantaged socioeconomic groups are more vulnerable to mental health problems, and mental health problems put those children at higher risk of mental and physical health problems in adulthood, as well as increased likelihood of unemployment, contact with law enforcement agencies and need for disability support (Collishaw et al., 2019; Patel et al., 2016). Approximately 47 child and adolescent psychiatrists would optimally serve a population of 100,000 youth ages 0–19 years of age (Guerrero et al., 2022). However, worldwide, this number is approximately 1.19 in high-income countries (World Health Organization, 2018). Concerningly, this number is less than 0.1 per 100,000 in the total population in low- and middle-income countries (LMICs). The majority of the world’s 2.2 billion children and adolescents reside in LMICs, which tend to have a younger population than high-income countries (Kieling et al., 2011).

Child and adolescent psychiatry has played an important role in advancing the scientific understanding of child and adolescent development, in integrating the efforts of multiple other disciplines and in improving the health of youth and families (Skokauskas et al., 2019). Today, child and adolescent psychiatry has to respond to the growing public health challenges associated with the large number of mental disorders arising early in life. There are various areas where child and adolescent psychiatry must further develop to meet the demands of 21st century practice. These areas include research literacy, collaborative care, population health, health policy, prevention and early intervention, teaching and training, cultural humility and trauma-informed care (Shaligram, Bernstein, et al., 2022).

This volume begins with an exploration of strategies to address the dearth of child and adolescent mental health services (CAMHS) by integrating CAMHS in primary care (Shaligram, Skokauskas, et al., 2022). Shaligram et al. have looked at various models of integrated care, namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US and Uruguay; coordinated care in the US and developing collaborative care models in low-resource settings like Kenya and Micronesia. The authors concluded that supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability (Shaligram, Skokauskas, et al., 2022).

Exposure to conflict, especially with increasing duration, is associated with an increased probability of delayed early childhood development, especially socioemotional development (Goto et al., 2021). With reference to the recent Russian invasion of Ukraine, these authors have appropriately identified war, which causes death and injury, toxic traumatic stress and deprivation of educational and other normative developmental opportunities, as a public health emergency (Goto et al., 2022). A paper published by Wang et al. in this issue draws our attention to child, adolescent an adult mental health services in Ukraine and some other Eurasian countries (Wang et al., 2022). Even before the war, Ukrainians had healthcare that lacked financial and human resources in general and mental healthcare in particular. In Ukraine and other included Eurasian countries, mental healthcare was predominantly based on inpatient hospital care, and outpatient community services remained under-resourced, especially for children and adolescents. Now is the right time to think about what kind of mental health services Ukraine should (re)build once the war is over, and what kind of model should be followed (i.e. Scandinavian or uniquely created).

In addition, even in high-resource settings, there exist disparities in mental health services and outcomes (including risks for psychiatric diagnoses, suicide death and legal system involvement) among different groups of a given population (Guerrero et al., 2022). These disparities are the product of differential exposures to poverty, trauma, discrimination and barriers to accessing mental healthcare. Addressing these disparities involves ensuring (through multidisciplinary collaboration, practice in settings beyond traditional healthcare settings and availability of technology) universal access to preventive and treatment-focused mental healthcare; hardwiring (through routine assessments and approaches that involve the family and community as appropriate) cultural humility in clinical and community settings and availability of workforce and expertise in the geographic locations where populations are otherwise underserved.

The COVID-19 pandemic further has revealed wide disparities in infection and recovery rates by race, ethnicity, socioeconomic status and place of residence (Garg et al., 2020). During the pandemic, youth have faced losses of primary or secondary caregivers or other family members to COVID-19, anxiety related to fears of contagion, distress related to other pandemic disruptions and direct medical sequelae. With the COVID-19 pandemic, a dual pernicious effect was exerted with the effects of increased social isolation and a global lack of sufficient workforce to directly interface with children and adolescent to help them.

As stated by T. McDonnell et al. in this special issue, the use of psychiatric services was much less early on in the pandemic due to services being minimized and consumers not wanting to take the risk of attending appointments (McDonnell et al., 2022). By 2021, there was increased use of telehealth services; an increase in emergency room visits for suicidal ideations, self-harm and suicide attempts and increased anxiety and depression. The disproportionate increase in admissions for MBN-PS (mental, behavioural, neuro-developmental disorders and psychosocial reasons) compared to medical admissions suggests an adverse effect of COVID-19 on youth mental health, for females in particular, and supports previous reports of a pandemic-specific increase in eating psychopathology. T. McDonnell et al. concluded that combined community and acute service delivery and capacity planning is urgently needed given the prior underfunding of services pre-pandemic (McDonnell et al., 2022).

During the COVID-19 pandemic, extraordinary measures, including closure of educational institutions, are being taken to protect the general population. When social distancing and quarantine constitute everyday life experiences, the effects of well-known and critical protective factors for resilience and mental health (i.e. social and community support) are substantially disrupted (Skokauskas et al., 2022). But online schooling provided some relief for at least one group of children and adolescents: those who experienced bullying at school. However, with schools being open again, effective bullying prevention is needed more than ever. Paradoxically, whole-school programs lead to higher levels of depression and poorer self-esteem for students who continue to be victimized after program implementation (Healy et al., 2022).

In this special issue, K.L. Healy at el. looked at the theoretical foundations and empirical evidence for reducing, through family interventions, the incidence and associated adverse mental health outcomes of school bullying victimization. The authors concluded that family interventions should be available to complement school efforts to reduce bullying and improve the mental health of young people (Healy et al., 2022).

This special issue ends with a genetics paper that elucidates the involvement of chromatin remodelling genes in the aetiology of autism spectrum disorder and Schizophrenia (Lo et al., 2022). There is strong evidence that genetic factors make substantial contributions to the aetiology of autism spectrum disorder, schizophrenia and bipolar disorders, with heritability estimates being at least 80% for each (Carroll & Owen, 2009). These illnesses have complex inheritance, with multiple genetic and environmental factors influencing disease risk; however, in psychiatry, complex genetics is further compounded by phenotypic complexity (Carroll & Owen, 2009). T. Lo et al.’s study supported the involvement of rare missense 30 variants of BAF genes in autism spectrum disorder and schizophrenia susceptibility (Lo et al., 2022).

One topic that is not covered by this special issue, and which is becoming increasingly important, is a climate change and mental health. This topic may warrant a special issue in the near future.

Climate change caused by human activities, notably fossil fuel consumption, poses a significant and disproportionate threat to those with mental health conditions. Climate change may cause: flooding, which in turn leads to acute drowning or trauma, injuries, disease spread; drought, which in turn leads to malnutrition, disease spread and fires; heat stress; decreased air quality and multiple other impacts. Global warming forces migration, precipitates conflict and violence, damages infrastructure, stresses healthcare systems and triggers anxiety and even existential angst (Coverdale et al., 2018). In these contexts, children may experience family disruption, homelessness, loss of social support and protection and victimization. Children may be vulnerable to Post-traumatic Stress Disorder, depressive disorders, substance use disorders and heightened suicide risk. Of note, hotter temperatures increase death rates in patients with psychosis and substance use. Certain regions of the world, notably island and coastal areas, urgently face multiple health impacts of elevated temperature, altered rainfall and more severe extreme weather events (e.g. tropical storms), ocean acidification and rising sea levels (Guerrero et al., 2020). Destruction or non-usability of ancestral and culturally significant land further adds to loss and trauma.

To be sustainable, child and adolescent psychiatry has to focus not merely on managing symptoms, but also on addressing a broad spectrum of underlying causes of diseases and employing innovative forms of collaborative care. Wars, pandemics, climate change, socioeconomic disparities already play a role in the mental state of children and adolescents. There is pressing need to address these environmental factors, employ the latest discoveries in biological psychiatry and increase the numbers of highly dedicated and well-trained professionals to help children and adolescents with mental healthcare needs.