IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

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MISCELLANEOUS

ORGANIZING AND DELIVERINGSERVICES FOR CHILD AND
ADOLESCENT MENTAL HEALTH
Chiara Servili

Chiara Servili MD, MPH
Consultant in Child andAdolescent Mental Health,
Department of Mental Healthand Substance Abuse, World
Health Organization, Geneva,
Switzerland
Conflict of interest: none
declaredMultidisciplinary team, Jordan
This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Servili C. Organizing and delivering services for child and adolescent mental health. In Rey JM (ed), IACAPAP
e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied
Professions 2012.

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1IACAPAP Textbook of Child and Adolescent Mental HealthM

ental health is a critical determinant of health and quality of life
across the life-span. According to the World Health Organization(WHO, 1948), health is defined as “a state of physical, mental andsocial well-being”. During childhood and adolescence, many factors can influencechildren’s and adolescents’ psychosocial well-being and their capacity to develop
to their optimal potential, cope with the normal stress of life, and contribute totheir communities. These factors can operate at the level of the individual, family,
school or neighbourhood, and at a broader societal level. Among others, thesefactors include inadequacies in the nurturing and stimulating nature of theirenvironment, parents' mental health, exposure to violence, abuse or neglect,
nutritional deficiencies and chronic medical illness (Kieling et al, 2011; Walker etal, 2007; 2011).
The more risks people experience early in life, the worse their developmental
outcomes and the higher the probability of experiencing psychological distressor mental health disorders (Sameroff et al, 2003). On the contrary, the more
opportunities they have in childhood and adolescence to experience and accumulate
the positive effects of protective factors that outweigh negative risk factors, themore likely they are to sustain mental health and wellbeing in later life (Currie& Todd, 2003). According to international evidence, 10%-20% of children andadolescents experience a mental health problem in any given year (WHO, 2001).
Yet, in most countries only a small minority of young people with mental healthproblems is able to access appropriate resources for recognition, support and care(Morris et al, 2011). Health services for children and adolescents who are at risk
but who do not yet exhibit clinical symptoms are even more inadequate (Knitzer,
2000).

INTERVENTIONS FOR CHILD AND ADOLESCENTMENTAL HEALTH (CAMH)
Meeting the mental health needs of children and adolescents requires the
setup of multi-layered care systems that include a range of promotive, preventive
and curative services. Table J.5.1 provides an overview of effective interventions
that can be implemented in countries with different levels of resources, including
low- and middle-income countries (Kieling, 2011; mhGAP Evidence Resource
Centre). These interventions are delivered in a variety of settings, such as schools,
homes, communities, and health facilities, and target diverse populations.
Among the preventive interventions, some of them (the so-called universal
interventions) target all children or adolescents in a particular locality or setting.
School-based physical activity programs, life skills training and restricting accessto means of self-harm are examples of universal interventions. Others (selective
interventions) focus on children exposed to risk factors for mental health problems,for example in the case of school-based psychosocial group interventions. Indicatedinterventions target children and adolescents experiencing subclinical symptoms;
early stimulation programs for children with developmental delays belong to thiscategory. Broad psychosocial strategies for mental health promotion in schools
and communities need to be coupled with targeted interventions addressing thespecific needs of young people with mental disorders and their families.

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2IACAPAP Textbook of Child and Adolescent Mental Health

Table J.5.1
Examples of interventions for the prevention andmanagement of mental health problems in children and adolescentsInterventions for developmental disorders

Prevention

Management

•
•
•
•
•

Maternal and child nutritional and micronutrient supplementation
Prenatal and perinatal care
Reduction of prenatal exposure to alcohol
Immunization programs, malaria prevention
Early stimulation programs.

•

Family psychoeducation and orientation about locally available
educational, social and rehabilitative services (including
community-based rehabilitation services)
Parenting skills training
Promotion of human rights of the child and the family
Provision of support to carers
Cognitive behavioral therapy targeting problem behaviors

•
•
•
•

Interventions for behavioral disorders•
Prevention

Management

•
•
•
•
•
•

School-based preventive interventions involving training ofteachers
Brief behavioral parent training intervention (integrated into childhealth services)
Family psychoeducation
Parenting skills training
Cognitive behavioral therapy and social skills training
Support to carers and families (to handle social and familial
problems and address carers’ mental health needs)
Pharmacological treatment for ADHD (prescribed by specialists,
for children older than 6 years of age).

Interventions for internalizing disorders
Prevention

Management••

School-based physical activity programs and life-skills training
School-based psychosocial group intervention for at-risk children

•
•
•
•

Family psychoeducation
Interpersonal psychotherapy
Cognitive behavioral therapy
Adjunct treatments (structured physical activity programs,
relaxation training and problem solving treatment)
Pharmacological treatment when appropriate•

Interventions for suicidal behavior•
Prevention•

Development of policies to reduce harmful use of alcohol andrestrict access to means of self-harm (such as pesticides andfirearms)
Assist and encourage the media to follow responsible reporting
practices of suicide events

Interventions for psychosis
Management•••

Psychoeducation for the young person and carers
Pharmacological treatment
Psychosocial interventions such as family therapy, social skills
training and rehabilitation

Sources: Kieling et al, 2011; mhGAP Evidence Resource Centre

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3IACAPAP Textbook of Child and Adolescent Mental HealthProfessionals at different levels of the health care system need to be engaged
in order to ensure timely recognition and management of specific mental healthneeds and vulnerabilities. Besides mental health specialists, health staff working atprimary health care level, teachers, social workers, families and other community
resources play important roles. The delivery of a comprehensive package of childand adolescent mental health interventions (including services described in Table
J.5.1) requires not only the right mix of trained personnel but also mechanisms for
integration of mental health into general healthcare, mechanisms for collaborationand liaison within the health system and across sectors, guidelines and clinicalprotocols for management of mental disorders in children, quality monitoring
programs, and adequate supply of medications (WHO, 2007).
The following sections describe guiding principles and required step-wise
actions for planning child and adolescent mental health services. Possible caremodels for the organization of services, particularly at primary health care level,
are also presented.

PRINCIPLES FOR THE ORGANIZATION OF CHILD
AND ADOLESCENT MENTAL HEALTH SERVICES
The organization of services for child and adolescent mental health needs
to take into consideration several strategic recommendations. Some are consistent
with the principles underpinning the organization of mental health services for
adults; others are based on specific considerations for this age group.
Child mental health specialists play an important role in sensitizing
governments on child mental health needs. They may act as expert advisors andcontribute to the planning and evaluation of mental health services. Furthermore,changes in the conceptualization of services have direct implications on childmental health specialists’ role. A good understanding of the main guiding principles
is therefore important for child psychiatrists and other professionals in the field.

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Training of mental healthstaff, Asmara, Eritrea, 20094

IACAPAP Textbook of Child and Adolescent Mental Health

The guiding principles listed below are based on strategic directions proposedby the WHO and on available international evidence from implementation research(WHO, 2005a; 2008a; WHO and World Organization of Family Doctors, 2008;
Eaton et al, 2011).
•

Integrate mental health in general health services
Physical and mental illness frequently coexist. Somatic complaints arecommon presentations for mental health problems in children and adolescents(Campo et al, 2004). In addition, children with chronic medical illnesses are
more prone to develop emotional and behavioral problems. Mainstreaming
mental health into general health services contributes to improved recognitionof mental disorders and ensures that physical healthcare needs of children withmental disorders are not neglected.

•

Improve equity and access to care by provision of care as close tocommunities as possible
Many people with mental disorders do not consider themselves to be in needof psychiatric care. Parents and adolescents may perceive psychiatric care as
stigmatizing. Utilization of mental health care services often improves whenservices are provided as part of primary health care. Provision of mental healthcare at primary care and community levels has the potential to increase accessto treatment and equity in access to care by making available services closer
to user’s homes and by reducing users’ direct and indirect costs (e.g. travel
expenses).

•

Promote a continuum of care
Addressing the mental health needs of young people requires the coordinatedaction of health professionals employed at various levels of the health system.
Even when mental health problems are recognized by primary care workers,
consultation with or referral to specialists may be necessary for further
assessment and management. Families of children with chronic mental
disorders, for example, developmental disorders, often report inadequate
coordination between pediatric and adult services. Procedures for coordination
between community care and specialized services and with adult facilities
improve the perceived quality of care.

•

Ensure inter-sectorial coordination
Children with mental disorders and their families have complex needs requiring
multi-sectorial responses. They need to have access to appropriate educationaland occupational opportunities and social and rehabilitation services. New
staff competences and structured mechanisms for inter-sectorial coordinationand multidisciplinary team approaches are needed.

•

Adopt an ecological approach
The psychosocial well-being of children is closely linked to the mental healthof parents and the quality of the family and school environments. Many
psychiatric disorders that have their onset during adolescence are connectedwith family problems and social difficulties, and are only understandable

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5IACAPAP Textbook of Child and Adolescent Mental Healthwhen viewed against this psychosocial context. Management of mental healthproblems in young people requires assessing the needs and resources in thefamily and active engagement of carers and teachers in treatment plans.
•

Adopt a life-cycle approach
Children have specific vulnerabilities as they grow up and acquire a set ofskills to cope with the adverse circumstances that will occur along their path.
Their mental health and well-being is influenced by early experiences and,even beyond that, by maternal exposure to nutritional deficiencies, hazardous
agents and stressful circumstances during pregnancy (Foresight Mental
Capital and Well-being Project, 2008; Fisher et al, 2011). If untreated, mental
disorders with onset during childhood and adolescence are likely to persist
and lead to poor health, educational and occupational outcomes later in life.
When planning services for children’s mental health promotion and care it isimportant to consider the entire range of opportunities for addressing early
determinants of child mental health, as for example by including maternal
mental health assessment and treatment in antenatal and postnatal visits.

•

Adopt a human rights-based approach to careChildren with mental disorders are often stigmatized and discriminated against
and, because of that, may be denied opportunities for adequate healthcare andeducation. They have the right to access quality mental health services that areappropriate to their needs, culture and gender. Healthcare workers can play a
key role by promoting behavior change in families, schools and communities,
and informing young people and their carers about their rights.

•

Promote users’ participation
Adolescents and children have the right to be informed about their healthproblems and participate in decision-making about their treatment (wheneverpossible, according to their age and developmental level, see Chapter A.1).
Carers and other available resources within the family, school and community
need to be engaged and empowered to assume active roles in promoting thepsychosocial well-being and functioning of young people.

•

Mainstream health promotion interventions in primary health caresettings
Interventions based on strategies for reducing risk and strengthening resilience
have proved effective for the prevention of mental disorders and promotion of
psychosocial wellbeing in young people. Because of the huge reach of primarycare services, the delivery of health promotion by general practitioners canhave a significant impact on youth mental health. This opportunity is often
untapped. The need for a paradigma shift in the role of primary health care
professionals to assume increased responsibility for health promotion has been
repeatedly emphasized (WHO, 2008b). Besides the role of medical services,
schools and families offer opportunities for sustainable health promotion
interventions. Parenting skills training and life skills training are examples ofhealth promotion interventions in the family and school setting respectively.

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6IACAPAP Textbook of Child and Adolescent Mental Health

PRACTICAL IMPLICATIONS OF ADOPTING THESE
GUIDING PRINCIPLES IN THE DELIVERY OF CAMH’S
INTERVENTIONS
Organization of services
Figure J.5.1 shows the optimal mix of services pyramid, a framework
developed by the WHO to provide guidance for the organization of mental healthservices. It also applies to CAMH services. The pyramid highlights the fact thattertiary and specialist services are very expensive and needed by only a small portionof the population, while informal, community-based and primary health careservices can be provided at a relatively low cost and are more frequently needed.
Young people use a variety of primary care services, such as maternal andchild health outpatient clinics, outreach services for vaccination and growthmonitoring, outpatient services for HIV counseling and testing, and familyplanning services. These are all potential entry points for providing mental healthpromotion and care to children and adolescents in need. Trained primary careproviders can address specific concerns about psychosocial distress and clinicalsymptoms for mental disorders. In some cases they also ask and assess for thepresence of specific symptoms as part of their routine work. As an example,
child development monitoring and early detection of developmental difficulties
can be part of routine child-well visits. In many countries child mental healthservices are provided by specialists in secondary and tertiary care settings only andincreasing access to mental health care in primary care settings requires a shift in
the organization of services and in the allocation of financial and human resources.
Community-based and informal care consists of services provided mainly
by peers, parents, school staff and influential community members. They play amajor role especially in terms of community sensitization on mental health needs,
promotion of attitudinal changes and promotion of psychosocial well-being.

Figure J.5.1

Service delivery		The optimal mix of services pyramid (WHO, 2007)

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IACAPAP Textbook of Child and Adolescent Mental HealthCommunity-based health workers may also be engaged in the delivery of services
relevant to child mental health and they can be considered an “extension” ofthe primary care services. Human resource policies have to consider the specifictraining needs and incentives for peers, parents, teachers, community leaders, andcommunity health teams according to their respective roles.

Attendees and Faculty,
IACAPAP Study Group in
Abuja, Nigeria, 2010

Policies and procedures for coordination and collaboration between services
National policies need to define pathways for coordination between services
within the health sector and across sectors (i.e., with schools, social services andother community services), including mechanisms for referral and referral back.
Traditionally, the organization of primary health care has relied on referral of allmental disorder cases to specialists. In most countries, specialists are available atsecondary or tertiary care levels only. Delivery of child mental health services ata primary health care level requires the establishment of structured mechanisms
for collaboration and team working, allowing primary care staff opportunities forregular consultation and supervision with specialists in mental health and related
disciplines (Bradley et al, 2003). In some cases, mental health specialists (e.g.,
psychiatric nurses, psychologists) are made available at primary health care leveland patients are referred by general practitioners to primary health care-based
mental health specialists, who assume responsibility for providing treatment. Thismodel is called the replacement model.
In collaborative models, general practitioners retain the primary responsibility
for care but professionals with complementary skills (traditionally mental healthprofessionals) work as part of a package of care, liaising with both patient andhealth worker to increase the overall effectiveness of treatment. Collaborative
approaches are based on a strong partnership between front line health workers
and other professionals with diverse expertise and mandates who work together
to meet the users’ needs. This implies task-shifting and task-sharing among a
multidisciplinary team of professionals. Collaborative approaches increase thefeasibility of assessment and management of mental disorders by busy healthworkers in community-based settings, while also promoting the provision of good

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8IACAPAP Textbook of Child and Adolescent Mental Healthquality and comprehensive mental health care. Evidence suggests that training ofgeneral practitioners and establishing collaborative care models may lead to greater
impact on the overall quality of care and promote a better and more equitable useof scarce specialized personnel.
Human resources policy
While human resources are the most valuable asset of mental health services,many countries face difficulties with availability of trained staff, especially in rural
settings and community-based services. Careful planning of training, specificationof the tasks to be performed and deployment of workers is critical. A reallocationof staff from institutions to community-based services and from urban to rural
areas may be needed, together with the recruitment and training of a wider rangeof workers at primary health care level. Strategies to improve staff retention
and motivation are equally important. They may include provision of ongoingeducation and support through team meetings, consultations and supportive
supervision.
Capacity building
General health care staff need to be trained in order to acquire basic mental
health competencies for the detection of common mental disorders, provision ofbasic treatment and psychoeducation, and referral to other community-based andspecialist services when necessary. Training materials address concerns about humanrights and promote attitudinal change to reduce stigmatization and discrimination
towards children with mental disorders and their families. Capacity building
materials ought to increase primary health workers’ awareness of their role for thepromotion of mental health. These new skills need to be updated and refreshedwith regular supportive supervision and on-site consultation and training.
Specialists in child mental health (pediatricians, mental health nurses,
psychiatrists, neurologists, child psychiatrists) require adequate skills to work

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World Mental Health Day
2009, Jordan

9IACAPAP Textbook of Child and Adolescent Mental Healthcollaboratively with general health workers and multidisciplinary teams andprovide them with supervision and support. In addition, the curriculum for arange of non-health professionals (e.g., social workers, community-based workers)
has to include a mental health component when relevant to their functions.
Monitoring quality of care
The definition of standards for and indicators of quality of care is key toassessing the effectiveness of organizational changes and capacity building efforts.
Important parameters for the evaluation of quality of child mental health careinclude:• Access and equity of access• Acceptability to users and staff• Users’ and carers’ satisfaction• Utilization of primary care services by children with mental disorders• Reduced number of cases requiring admission to in-patient services or
tertiary level outpatient visits• Reduced clinical symptoms and improved functioning in daily life.

IMPROVING SERVICES FOR CAMH: A STEP-WISE
APPROACH
How to operationalize the theoretical considerations mentioned above?
Where to start planning or improving services for CAMH? There are a numberof key actions needed. They are summarized in Figure J.5.2. It is not important
to strictly follow the order of suggested actions, it is much more important toensure ownership throughout the entire process by a comprehensive team of local
stakeholders and active participation of users’ representatives.
An example of a global initiative for scaling up mental health care: themhGAP program
The World Health Organization recently launched the Mental Health Gap
Action Program (WHO, 2008a; 2010) aiming to increase coverage of key mental
health interventions, particularly in low- and middle-income countries. The
program provides technical guidance for the development and implementation ofnational strategies for scaling up mental health care. It adopts a life-cycle approachand targets children and adolescents, among other age groups. The following are
the critical assumptions:•

Mental health care has to be integrated into general health services andmainstreamed in primary care settings•

Non-specialist health care professionals at primary health care level,
when receiving appropriate training, can recognize common mental,
neurological and substance abuse conditions and provide first-line
interventions.

Figure J.5.3 illustrates the mhGAP suggested approach for improving
availability of and access to treatment for children and families in need. Core
components of the program are the definition of the package of interventions
and development of strategies for increasing coverage of those interventions.
A template for a package of interventions that can be provided at primary andService delivery		

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.5.2

A step-wise approach for improving services for CAMH
Assess needs and resources

•
•
•
•
•
•
•

Epidemiological data on mental health needs of target groups
Skills and training needs of care providers and other professionals
Access and utilization of health facilities
Availability of drugs
Organization of health care services and opportunities for mainstreaming mental health
Mechanisms for integration of primary and secondary care and for inter-sectoral collaboration
Health care financing

Increase awareness on mental health needs of children and adolescents

Promote ownership by establishing or engaging technical committees of relevant
stakeholders

Develop or adapt a strategy for improvement of CAMH services according to local needs
and local health system
This strategy will have to include a definition of the human resources (e.g., distribution of tasks, curriculum,mechanisms for the incorporation of mental health care into the existing health system, modalities for the integration
between primary and secondary care and inter-sectoral collaboration, and procedures for monitoring the quality ofservices).

Implement the strategy
•
•
•
•
•
•

Orient program managers at national and district levels on CAMH strategy
Address gaps in existing policies and laws relevant to mental health and human rights of young people withmental disorders
Select packages of evidence-based interventions and adapt to local settings
Build capacities of staff in the health sector (including primary and community-based health workers) and otherrelated disciplines (both pre-service and in-service training)
Ensure appropriate supervision, consultation and continuing education
Conduct community awareness campaigns on child mental health and the role of communities

Evaluate implementation of the strategy

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure J.5.3

mhGAP framework for action.

secondary care levels by non-specialist health care workers has been made available
to countries (Dua et al, 2011) but it needs to be adapted to the local context. A
team of international experts (Guidelines Development Committee) defined thecontent of the mhGAP intervention package on the basis of available scientificevidence and agreed criteria. Mental, neurological and substance use disorders that
represent a high burden (in terms of mortality, morbidity and disability), cause large
economic costs, or are associated with violations of human rights were identified
as priority conditions. Cost-effective, acceptable and feasible interventions forprevention, detection and management of these conditions were then included in
the package. The interventions are directed at individuals or populations.
Mental disorders in children were identified among the priority conditions.
Developmental and behavioral disorders are specifically addressed in the mhGAP
intervention package. Specific interventions for the management of depression,
epilepsy, psychosis and alcohol and drug abuse in children and adolescents are also
included. Table J.5.2 provides examples of evidence-based recommendations forassessment and management of mental disorders in children that were developedby the guidelines development committee.
At country level, a technical task force has to define mechanisms for thedelivery and scale-up of the intervention package: at what level of the health caresystem the interventions will be delivered, who will be responsible for delivering theinterventions, and what changes in work tasks, training curricula, and procedures
are required. For example, assessment and management of developmental
disorders at a primary health care level implies the establishment of structured
collaboration mechanisms with mental health specialists, schools, and socialand rehabilitation services. As a consequence there may be a need to modify theService delivery		

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Click on the picture toaccess evidence-based
clinical guidelines for the
management of priority
conditions by non-specialist
health care providers at
primary health care level.
It provides flowcharts toguide assessment andmanagement and is available
in several languages.

12IACAPAP Textbook of Child and Adolescent Mental Health

Table J.5.2
Recommendations for child and adolescent mental health conditions by mhGAP
guidelines development committee

Maternal mental healthinterventions

Parent skills training for
behavioral disorders
Parent skills training
for developmental
disordersChild abuse

Intellectual disabilities

Behaviour disorders(attention deficit
hyperactivity disorder)

Pharmacologicalinterventions forchildren with disruptive
behavior disorders or
conduct disorder or
oppositional defiant
disorderSomatoform disorders
Antidepressants forchildren with depression
Antidepressants foradolescents withdepression
Pharmacologicalinterventions for anxiety
disorders in children
and adolescents
Behavior change
techniques forpromoting mental healthService delivery		

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CAMH 1. For at-risk children, parenting interventions promoting mother-infant interactions,
including psychosocial stimulation, should be offered to improve child development
outcomes. To improve child development outcomes, mothers with depression or with anyother mental, neurological or substance use condition should be treated using effective
interventions (see recommendations for treatment of depression and other mental,
neurological or substance use conditions).
CAMH 5. Parent skills training should be considered for the treatment of emotional andbehavioral disorders in children aged 0-7 years. The content should be culture sensitive
but should not allow violation of children’s basic human rights according to internationallyendorsed principles.
CAMH 6. Parent skills training should be considered in the management of children withintellectual disabilities and pervasive developmental disorders (including autism). Suchtraining should use culturally appropriate training material.
CAMH 2. Non-specialized health care facilities should consider home visiting and offer
parent education to prevent child abuse especially among at-risk individuals and families.
They should also collaborate with school-based “sexual abuse prevention” programs
where available.
CAMH3. Non-specialized health care providers should consider assessment and regularmonitoring of children suspected of intellectual and other developmental delays by brief
locally validated questionnaires. Clinical assessment under the supervision of specialists
to identify common causes of these conditions should be considered.
CAMH 4. Non-specialized health care providers should consider supporting, collaborating
with, and facilitating referral to and from community-based rehabilitation programs.
CAMH 7. Non-specialized health care providers at the secondary level should consider
initiating parent education/training before starting medication for a child who has been
diagnosed as suffering from ADHD. Initial interventions may include cognitive behavioral
therapy (CBT) and social skills training if feasible.
Methylphenidate may be considered, when available, after a careful assessment of thechild, preferably in a consultation with the relevant specialist and taking into consideration
the preferences of parents and children.
CAMH 8. Pharmacological interventions (such as methylphenidate, lithium, carbamazepine
and risperidone) should not be offered by non-specialized health care providers to treat
disruptive behavior disorders (DBD), conduct disorder (CD), oppositional defiant disorder(ODD) and comorbid ADHD. For these conditions, the patients should be referred to a
specialist before prescribing any medicines.
CAMH 9. Pharmacological interventions should not be considered by non-specialized
health care providers. Brief psychological interventions, including CBT, should beconsidered to treat somatoform disorders in children, if adequate training and supervisionby specialists can be made available.
CAMH 10. Antidepressants should not be used for the treatment of children 6-12 years ofage with depressive episode/ disorder in non-specialist settings.
CAMH 11. Fluoxetine, but not tricyclic antidepressants (TCA) or other selective serotonin
reuptake inhibitors (SSRI), may be considered as one possible treatment in non-specialist
settings of adolescents with depressive episodes.
Adolescents on fluoxetine should be monitored closely for suicide ideas/ behavior. Supportand supervision from a mental health specialist should be obtained, if available.
CAMH 12. Pharmacological interventions should not be considered in children andadolescents with anxiety disorders in non-specialist settings.
CAMH 13. Non-specialized health care facilities should encourage and collaborate withschool-based life skills education, if feasible, to promote mental health in children andadolescents.

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IACAPAP Textbook of Child and Adolescent Mental Healthdescription of management tasks of primary care workers to include liaising withsocial services and community resources, providing advice to teachers and, when
feasible, skills training to parents. Organizational changes and modification in the
distribution of tasks and health professionals’ curricula at various health care levels
are often required. For example, whenever a parent expresses concerns about theirchild’s development, the primary health care staff at the outpatient service canassess the problem, manage any co-occurring medical condition, provide family
psychoeducation, and then refer the child to other primary health care outpatient
services for follow up and more intensive psychosocial interventions (including
parent skills training).
The assessment of needs and available resources is a critical preliminary
activity that informs the adaptation of mhGAP template to the local needs, thedesign of national and regional strategies for its implementation, and prioritizationand phasing of interventions. Success in the implementation of the program
depends on political commitment at country level. The development/improvementof relevant policy and legal frameworks is important to ensure conditions favorable
to the implementation of the program and respect of the human rights of children
and adolescents with mental health problems.
A monitoring and evaluation framework is built into the program. A variety
of tools is available or being developed to assist countries in its implementation,
including an orientation guide for program managers, templates for the adaptation
process, questionnaires for the needs assessment, training materials, and supervisory
checklists.

Maternal, child and adolescent mental health in the Eastern
Mediterranean Region: strategic planning towards improved care
The World Health Organization Regional Office for the Eastern Mediterranean
Region has recently undertaken concerted efforts towards the improvement of maternal,
child and adolescent mental health services in countries of the region encompassing the
crescent extending from Pakistan in the East to Morocco in the West.
The WHO initiated and led a participatory process for the development of Regional
Strategic Directions and Actions for Maternal, Child and Adolescent Mental Health Careby working closely with Ministries of Health in the region and availing itself of the technicalsupport of experts in the field. The regional strategic document was discussed during an
Intercountry Meeting on 26th-28th July 2010 in Cairo. The meeting was attended by mental
health focal points from 21 of the 22 member states of the region in addition to WHO staff
and experts.
Participants reached an agreement on key strategic actions to be promoted andundertaken at regional and country levels in the six years’ operative period (2010-2015). In
particular, the need to assess mental health service gaps and map available resources forchild and maternal mental health care was emphasized. Development of human resources,
integration of MCAMH interventions within existing primary health care services, promotionof mental health, and strengthening research and monitoring and evaluation were identified
as critical needs to be addressed.

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Campo JV, Bridge J, Ehmann M et al (2004). Recurrent
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Currie C, Todd J (2003). HBSC briefing paper 2: mental
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Age and Gender Patterns, Trends and Cross-National
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Dua T, Barbui C, Clark N et al (2011). Evidence-Based
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Summary of WHO Recommendations. PLoS Med
8(11):e1001122.
Eaton J, McCay L, Semrau M et al (2011). Scale up of services
for mental health in low income and middle-income
countries. Lancet, 378:1592-1603.
Fisher JRW, Cabral de Mello M, Izutsu T et al (2011).
Adolescent Mental Health in Resource-Constrained
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