Blog 3

Prevalence of mental health problems that children in low and middle income countries face

Mental illness accounts for approximately 14% of the global burden of disease¹⁸. Depression and anxiety are some of the leading causes of disability worldwide¹⁸. Mental health problems affect 10-20% of children and adolescents worldwide and a majority of them come from LMICs⁶. These conditions often develop in children during their childhood and adolescence years and if left untreated can cause negative effects to their social functioning skills¹⁸. Other long term outcomes include adult criminal violence, drug misuse, school failure, teenage pregnancy and unemployment³. Mental illness in low and middle-income countries (LMICs) is a global concern as over 80% of those with mental disorders reside in these countries and their youth population are the ones most vulnerable⁸. Many LMICs are affected by armed conflict, violence and natural disasters, which significantly affects the mental development and well-being of the population’s children¹¹. Additionally, children in LMICs have a greater risk of developing depression, anxiety and post-traumatic stress disorder (PTSD)¹¹ due to living in harsh environments. Availability and access to mental health services for children have been found to be limited and inadequate¹⁴.

Why are early childhood interventions important in the promotion of children’s mental well-being? 

Interventions to improve child development, prevent mental health problems and promote well-being should be a global health priority. This is because, experiences in early childhood have a long-term effects on the child’s brain function, cognition and psychosocial functioning¹. Exposure to adverse environments during a child’s first few years of life have been shown to predict lower IQ levels and academic achievement, increase anti-social behaviour, lower economic productivity and poor health and chronic disease in adulthood⁵. Therefore, the foundations for a stable adult physical and mental health must be laid during the early childhood years. Quality of parenting and child IQ have been found to be effective protective factors for children growing up under disadvantaged circumstances⁷. Quality of parenting is determined by the skills, knowledge and mental health of the caregiver¹⁷. Studies have found that maternal depression negatively affects parenting quality and child development¹⁵. On the other hand, the quality of early childhood classroom environment is seen as both a risk and protective factor for child behaviour management and adjustment. There is evidence showing the benefits of early childhood interventions such as promoting children’s cognitive development and sustaining it over a period of time². Interventions aimed at improving children’s nutrition and educational outcomes in LMICs, have also been found to strongly benefit their cognitive development and improved their educational outcomes¹⁰. Literacy programmes have also been found to have had an unanticipated benefit on children’s mental health by reducing feelings of hopelessness⁸.

How are children’s mental health problems treated in low and middle-income countries?

• Choose the interventions that have displayed clear benefits¹²
• Parent training and centre-based programmes
• Interventions should also be culturally appropriate and economically feasible⁴
• From 10 weeks to 3 years or more
• Target group (e.g. prenatal, new-born, infants over 6 months and children between 3-6 years)
• Risk status of mothers (e.g. HIV infected) 
• Interventions that incorporate hand-on-practice, role-play, supportive feedback, practice activities have been shown to be effective in changing the caregivers’ behaviour¹
• Health status of the child (e.g. stunted, anaemic or undernourished)
• Delivered by paraprofessionals
• A manual with a structured curriculum, training guide and monitoring instruments are important for maintaining quality of intervention¹
• Paraprofessionals are able to deliver interventions at a high level of quality provided that they receive adequate training and supervision¹
• Benefits to child mental health were observed:
• Reduced anxiety, depression, anti-social behaviour in adulthood¹⁶
• Another study looked into the effects of attending a high quality preschool programme as compared to a low quality preschool programme. The intervention involved educational activities, nutrition and physical exercise activities. As a result the researchers found:
• A reduction in schizotypal personality, (b) cognitive disorganisation, (c) conduct disorder, (d) psychotic behaviour, (e) motor excess at 17 years and (f) reduced criminal offending at 23 years¹³.

Conclusions 

• Mental illness accounts for approximately 14% of the global burden of disease
• Mental health problems affect 10-20% of children and adolescents worldwide and a majority of them come from LMICs
• Many LMICs are affected by armed conflict, violence and natural disasters, which significantly affects the mental development and well-being of the population’s children
• Interventions to improve child development, prevent mental health problems and promote well-being should be a global health priority
• This is because, experiences in early childhood have a long-term effects on the child’s brain function, cognition and psychosocial functioning
• Therefore, the foundations for a stable adult physical and mental health must be laid during the early childhood years. Quality of parenting and child IQ have been found to be effective protective factors for children growing up under disadvantaged circumstances
• Some of the ways that early childhood interventions are being implemented in LMICs to combat mental health problems include:
• Implementing interventions that ‘works’ or display clear benefits
• Can be either parent training programmes and centre-based programmes
• Interventions are delivered by paraprofessionals that are trained and supervised 

References used:

1. Baker-Henningham, H. (2013). The role of early childhood education programmes in the promotion of child and adolescent mental health in low- and middle-income countries. International Journal Of Epidemiology, 43(2), 407-433. doi: 10.1093/ije/dyt226
2. Engle, P., Fernald, L., Alderman, H., Behrman, J., O’Gara, C., & Yousafzai, A. et al. (2011). Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet, 378(9799), 1339-1353. doi: 10.1016/s0140-6736(11)60889-1
3. Fergusson, D., John Horwood, L., & Ridder, E. (2005). Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal Of Child Psychology And Psychiatry, 46(8), 837-849. doi: 10.1111/j.1469-7610.2004.00387.x
4. Grantham-McGregor, S., Powell, C., Walker, S., & Himes, J. (1991). Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. The Lancet, 338(8758), 1-5. doi: 10.1016/0140-6736(91)90001-6
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11. Punamäki, R. (2002). The uninvited guest of war enters childhood: Developmental and personality aspects of war and military violence. Traumatology, 8(3), 181-204. doi: 10.1177/153476560200800305
12. Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trial. The Lancet, 372(9642), 902-909. doi: 10.1016/s0140-6736(08)61400-2
13. Raine, A., Mellingen, K., Liu, J., Venables, P., & Mednick, S. (2003). Effects of Environmental Enrichment at Ages 3–5 Years on Schizotypal Personality and Antisocial Behavior at Ages 17 and 23 Years. American Journal Of Psychiatry, 160(9), 1627-1635. doi: 10.1176/appi.ajp.160.9.1627
14. Saxena, S., Lora, A., Morris, J., Berrino, A., Esparza, P., & Barrett, T. et al. (2011). Focus on Global Mental Health: Mental Health Services in 42 Low- and Middle-Income Countries: A WHO-AIMS Cross-National Analysis. Psychiatric Services, 62(2), 123-125. doi: 10.1176/ps.62.2.pss6202_0123
15. Wachs, T., Black, M., & Engle, P. (2009). Maternal Depression: A Global Threat to Children’s Health, Development, and Behavior and to Human Rights. Child Development Perspectives, 3(1), 51-59. doi: 10.1111/j.1750-8606.2008.00077.x
16. Walker, S., Chang, S., Vera-Hernandez, M., & Grantham-McGregor, S. (2011). Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior. PEDIATRICS, 127(5), 849-857. doi: 10.1542/peds.2010-2231
17. Walker, S., Wachs, T., Grantham-McGregor, S., Black, M., Nelson, C., & Huffman, S. et al. (2011). Inequality in early childhood: risk and protective factors for early child development. The Lancet, 378(9799), 1325-1338. doi: 10.1016/s0140-6736(11)60555-2
18. Yatham, S., Sivathasan, S., Yoon, R., da Silva, T., & Ravindran, A. (2018). Depression, anxiety, and post-traumatic stress disorder among youth in low and middle income countries: A review of prevalence and treatment interventions. Asian Journal Of Psychiatry, 38, 78-91. doi: 10.1016/j.ajp.2017.10.029