Introduction

Childhood mental health is defined by the World Health Organization (WHO) as “having a positive sense of identity, the ability to manage thoughts and emotions, as well as to build social relationships, and the aptitude to learn and to acquire an education, ultimately enabling full active participation in society” (WHO, 2013, p. 6). WHO (2012) also stated that

young people with a good sense of mental well-being possess problem-solving skills, social competence and a sense of purpose, which helps them rebound from any setbacks that they encounter, thrive in the face of poor circumstances, avoid risk-taking behavior and continue a productive life.

Children and adolescents are challenged with serious obstacles to their mental health regardless of whether they live in developing or developed countries (Achenbach & Rescorla, 2007; Belfer, 2008). These obstacles include abandonment, neglect, child abuse, family instability, parent psychopathology, poverty, dislocation, exposure to traumatic events such as violence, disaster, and, in some parts of the world, child prostitution and child soldiering (Masten, 2014). Additionally, children constitute up to half of the population in many developing countries with basic needs for nutrition, water and sanitation taking precedence over child mental health concerns (Belfer & Nurcombe, 2007; Patel, Flisher, Nikapota, & Malhotra, 2008).

Epidemiological data consistently report the global prevalence of child and adolescent mental disorders to be approximately 20 percent (Kieling et al., 2011; Klasen & Crombag, 2013; WHO, 2012) and suicide to be the second leading cause of death in the 15–19 years age category worldwide (Patton et al., 2009; WHO, 2012). Mental health challenges and disorders can result when children’s vulnerabilities and risk factors outweigh their resilience and protective factors. Child mental disorders can manifest themselves in many domains and in many different ways. It is now understood that mental disturbances at a young age can lead to ongoing impairment in adult life (Belfer, 2008; Flament et al., 2007; Kessler et al., 2005; Merikangas, Nakamura, & Kessler, 2009) and up to 50 percent of adult mental disorders have their origin in childhood (Belfer, 2008). Thus, the lack of attention to the mental health of children and adolescents not only leads to mental disorders with lifelong consequences to the quality of life for individuals, but to a reduced capacity of societies to be safe and productive.

In 1989, the Convention on the Rights of the Child (CRC) was adopted by the United Nations General Assembly (United Nations Children’s Fund (UNICEF), 2009; WHO, 2005a). CRC, the most universally endorsed and comprehensive human rights treaty of all time (WHO, 2005a), was a major and historic milestone in the effort to promote mental health and well-being in children around the world. It advocated for children having the right to survive and develop, and to be protected from violence, abuse and exploitation. The treaty also called for the views of children to be respected, and actions concerning them to be taken in their best interests (UNICEF, 2009). However, despite this effort to identify characteristics and environments that support healthy growth and development of children, the magnitude and impact of mental health problems were not properly recognized by many governments and policy makers in the world and continue to be unrecognized to this day, as many countries have chosen not to endorse the CRC.

Recently, the WHO has started playing a major role in raising public awareness of child mental health and facilitating the establishment of appropriate services (Belfer, 2008; Kieling et al., 2011). In 2002, it convened an expert panel to deliberate the status of children with mental disorders, especially in developing countries, and issued its report, Caring for Children and Adolescents with Mental Disorders: Setting WHO directions (WHO, 2003) to establish a framework for understanding the overall scope of the problems associated with launching a system of care for the treatment of child mental disorders. In 2005, WHO also published The Child and Adolescent Mental Health Atlas (WHO, 2005a), which is one of the first systematic efforts to collect data on treatment resources available for children and adolescents with mental disorders worldwide. The WHO ATLAS project was complemented by another publication, Child and Adolescent Mental Health Policies and Plans (WHO, 2005b), in order to provide practical information and guidelines for developing mental health policies and strategies. These efforts demonstrated the WHO’s recognition of the fundamental worldwide absence of mental health policy for children and its negative impact on healthy development. In these documents, nurses, as the largest group of health care providers, were being asked to serve as frontline providers in delivering services to children with mental disorders (WHO, 2011). While these documents provide us with epidemiological data on child disorders and policy recommendations, there is also a need for robust guidelines for child mental health promotion especially in low- and middle-income environments.

This chapter will describe risks, protective factors, and global issues impacting children’s mental health. It will further explore common mental health challenges and disorders, mental health promotion strategies, prevention programs for this population and opportunities for nurses, as the largest health care providers globally, to meet the mental health needs of children, adolescents and their families.

(Throughout this chapter, the term “children” will include adolescents unless otherwise specified.)

Etiology of childhood psychiatric and behavioral syndromes

Before embarking upon a discussion of variance from “normal” development of behavior and cognition in the form of syndromes and disorders, and in the case of illness acute variance, it is always worthwhile to briefly review what we consider to be normal.

Although the unified theories of cognitive development (Piaget), identity (Erickson), and moral reasoning (Kohlberg) have been critiqued, they remain valuable in that they provide a base from which to articulate variance. It must be noted that heterogeneity of people is the rule rather than the exception within age groups, but also within countries and cultures (Smetana, Campione-Barr and Metzger, 2006). Varied ways of thinking about development have been presented through consideration of information processing (largely development of attention, memory, and use of images) and the socially mediated aspects represented in ecology, among others. Table 18.1 provides a quick overview of development as represented in the staged approach used by Piaget, Erickson, and Kohlberg. Piaget’s work focused on the development of mental schemata and the assimilation of these into daily life (Piaget, 1952). Erickson focused on the development of identity (1952/1998) and Kohlberg on moral development in the context of shifting views from those traditionally held that moral education was the province of the family and church alone, which left little space to consider the role of school professionals and others in this endeavor (Kohlberg and Hersh, 1977).

Summary of developmental theorists

It is of note that adolescence is a time of upheaval and crisis that is in and of itself developmentally normal. Preceding the theorists featured in Table 18.1, Mitchell (1924) provided an apt description of the depth of normal teenage upheaval in the context of rapid physiological change and cognitive development:

The adolescent youth is an unbalanced and lumbering creature. He finds it difficult to make his way around in a world littered with obstacles. He is constantly running into furniture. He is awkward in making delicate distinctions and in observing the nice decisions of society. His hands and feet are large. He finds the world an uncharted sea in which he is constantly making mistakes. Our customary attitude toward him is one of reproof and condemnation. We urge him to conform to set standards but the very nature of his mechanism at this time makes conformity impossible . . . The adolescent girl in her development parallels that of the youth. Her awkwardness may be not so marked and she seems to recover from it more quickly.

The causes of most psychiatric disorders and behavioral challenges involve some combination of biological and psychosocial factors. Furthermore, child psychiatric symptoms are mitigated by the child’s cognitive, social, emotional, and developmental stages and socio-cultural context. The extent and nature of the influence of the child’s surroundings, such as family, peers, school, community, and cultural group, depend on the developmental stage and age of the child (Patel, Flisher, & Cohen, 2006; Paula, Duarte, & Bordin, 2007). Also, culture can create specific sources of distress and impairment in children, and influence how symptoms are interpreted (Kieling et al., 2011).

The concept of risk and protective factors

Researchers explain the etiology of mental disorders in children in association with risk and protective factors. A risk factor is a variable associated with an increased risk of psychopathology whereas a protective factor is a variable that moderates the effects of risk exposure. Furthermore, risks can be either modifiable (can be influenced or altered) or non-modifiable (cannot be influenced or altered). Children are more vulnerable to developing psychiatric and behavioral symptoms when risk factors surpass protective factors. In the meantime, protective factors can act by promoting alternative, compensatory processes that enhance self-esteem and a sense of personal effectiveness (Nurcombe, 2007). The more opportunities children have to experience the positive effects of protective factors, the more likely they are to be able to sustain mental health later in life (WHO, 2012). In general, both risk factors and protective factors can be understood in the context of three domains—biological, psychological, and social. Table 18.2 provides a description of risk and protective factors for children’s mental health.

Global risk factors

In addition to the aforementioned risk factors within low, middle-, and high-income communities, there are worldwide crises that can also impact child mental health. Many children may show resilience in response to these global phenomena especially with the appropriate scaffolding from adults and community resources. However, severe traumas will place vulnerable children at a significantly higher risk of experiencing mental health problems.

Resilience

Globally, tens of millions of children each year are exposed to terrifying phenomena such as disasters, political violence, displacement, child trafficking, pandemics, malnutrition, neglect, and abuse that threaten child development and well-being (Masten, 2014). In spite of such significant adversities or risks, there are some children who adapt successfully. These children are often called “resilient”(Garmezy, 1991; Rutter, 1987), “invulnerable” (Caffo & Belaise, 2007) and “stress-resistant” (Luthar & Zigler, 1991; Rutter, 1987). Rutter (2012) has defined “resilience” as “reduced vulnerability to environmental risk experiences, the overcoming of a stress or adversity, or a relatively good outcome despite risk experiences” (p. 336). In understanding the concept of “resilience,” two pivotal conditions are necessary: exposure to significant threat or severe adversity and the achievement of positive adaptation despite major assaults on the developmental process (Luthar, Cicchetti, & Becker, 2000).

According to Kieling and colleagues (2011), resilience is related to the concept of protective factors, but it focuses more on a child’s ability to regulate his/her own behavior and emotions to endure chronic stress or overcome trauma. Although early studies were mostly focused on personal qualities of “resilient children,” such as self-esteem (Masten & Garmezy, 1985), and social competence (Luthar & Zigler, 1991), there has been a change of paradigm in resilience as research has progressed. It has been acknowledged that resilience may often stem from factors external to the child (Luthar et al., 2000). Garmezy (1991) has emphasized that resilience is best understood in three domains: the child, the family, and the community. He has suggested that the presence of some caring adults such as grandparents, kindly concerned teachers, or the presence of an institutional structure, such as a caring agency or a church, could foster resilience in children in the absence of responsive parents or in the presence of marked marital discord (Garmezy, 1991). Walsh (2003; 2007) has conceptualized the new notion of “family resilience,” which has shifted attention from family as a protective factor for the child to family as the functional unit of resilience. The concept of “community resilience” has also been formulated by Landau (2007; 2010) based on her global experience in disaster recovery. She defined “community resilience” as “the community’s inherent capacity, hope, and faith to withstand major trauma, overcome adversity, and to prevail, with increased resources, competence, and connectedness” (Landau, 2007, p. 352).

Many scholars who are concerned with the impact of extreme adversity on children have found that children can actually grow stronger through such adversity with the support of family and community (Masten, 2014; Masten & Narayan, 2012; Landau, 2010; Walsh, 2007). Rutter (2012) has also supported this finding with the introduction of two new concepts: the notion of “steeling effects,” where engagement with stress serves to prepare the individual for better subsequent adaptation, and the notion of “turning point effects,” where negative life experience or adversity eventually serve to give more opportunities to individuals in life.

Assessing children and adolescents

Childhood impairment can be defined as a deficiency in adaptive functioning for the child’s developmental stage within his/her specific cultural context (Paula et al., 2007). There has traditionally been a focus on disorders when discussing child and adolescent mental health. However, maintaining this focus only serves to foster stigma and a pathologizing approach rather than supporting a mental health promotion perspective. Thus, culture-specific tools are important to properly assess both resilience and impairment in children. Unfortunately, nomenclatures that describe mental disorders in this section are based on the two most frequently used diagnostic classifications of mental illnesses, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) and the World Health Organization’s International Classification of Diseases (ICD). These classifications are grounded in Western conceptualizations (Schwab-Stone, Ruchkin, Vermeiren, & Leckman, 2001), which may fail to integrate meaningful cultural perspectives and context in classifying mental and behavioral disorders of children from other parts of the world and limit the understanding of mental disorders and challenges in these children (Belfer, 2008).

The following neuropsychiatric symptoms are identified as the most significant challenges in children across the world based on frequency of occurrence and degree of associated impairment. Merikangas, Nakamura, and Kessler (2009) have reported that about one-third of children experience a mental disorder over their lifetime. The most prevalent conditions in children are anxiety, followed by behavioral, mood, and substance use (Belfer, 2008; Merikangas et al., 2009). In particular, adolescents with mental health problems demonstrate high rates of suicidal behaviors and of tobacco, alcohol, and other drug use (Centers for Disease Control and Prevention, 2013; Flament et al., 2007). Nurses need to be knowledgeable about the diagnoses and clinical features associated with major childhood behavioral and mental disorders, as a necessary prerequisite for both needs assessment and the provision of good child mental health care.

Developmental challenges

Consistent with all the syndromes considered by child and adolescent psychiatric nurses, neurodevelopmental disorders have onset in a period characterized by intense development. However this particular subset of disorders affect the youngest of our population, and are frequently recognized in early childhood (American Psychiatric Association, 2013). The context of social impairment is often seen in early play and relationships with family and peers and occupational function is seen in pre-school or early school performance. Developmental deficits can involve limitations of learning, of executive functioning, of intelligence or impairment of social skills (American Psychiatric Association, 2013) as well as limitations in physical functioning.

Diagnosis of behavioral disorders is a probabilistic statement (Szatmari, Archer, Fisman, Streiner, & Wilson, 1995). That is, a behavioral diagnosis as a professional construct is a descriptor of behaviors that fit most closely with those exhibited by the young person. Validated tools are often used to record observations and aid in answering how the intensity and frequency of observed behaviors, or performance, compares to population means. This is important information in terms of distinguishing when to make the determination that behavior is outside the range of that typically expected within the developmental and cultural context, and within the bounds of a diagnostic category. Clinician judgment is also required as many of the neurodevelopmental disorders impact an individual’s ability to actively participate in the assessment process (American Psychiatric Association, 2013). Social impairment, impairments of attention, and physical impairment can all impact on test ability. Further, the thinking and information style in some groups, such as impaired abstraction in autism (Cashin & Barker, 2009; Cashin, Gallagher, Newman, & Hughes, 2012) and other forms of intellectual disability (American Psychiatric Association, 2013) may impact on the person’s ability to understand questions designed for a neurotypical population. Disorders that involve perception, such as some communication disorders may interfere with decoding messages or responding. In the subset of neurodevelopmental disorders there is a propensity for co-morbidity of physical or behavioral disorders (American Psychiatric Association, 2013).

As the neurodevelopmental disorders are diagnosed in early childhood there is also frequently a change of diagnosis as further development in the child allows for the emergence of a fuller understanding of the profile of psychiatric disability. One common example is when a child in preschool is observed to have problems with attention and focus and is diagnosed with attention deficit hyperactivity disorder (ADHD) and a trial of stimulant medications may be started. The child then enters school, and is observed to be defiant and to not follow directions, and a diagnosis of oppositional defiance disorder (ODD) is added. As part of refusing to follow directions it is observed that the child has high preference routines and activities, and later obsessive-compulsive disorder (OCD) may be added. Soon after a more complete picture emerges when difficulty interacting with peers is observed and a diagnosis of an autism spectrum disorder (ASD) is made. As a more thorough probabilistic statement is made and diagnosis refined, it is important to consider whether true comorbidity exists, or whether the new diagnosis better explains earlier understandings and requires removal of the earlier diagnoses.

Stretching the above example into adolescence further demonstrates the need to understand diagnosis as being within the context of a particular time and available data. Many of the disorders in the category of neurodevelopmental disorders, although often diagnosed in childhood are pervasive and lifelong (American Psychiatric Association, 2013). Nomenclature in the DSM refers to disability as opposed to delay to reflect this feature. Delay has the unfortunate implication that catch-up will occur. We are in many countries used to delayed public transport and familiar with the expectation that, although perhaps late, we will arrive at the destination. For some neuro developmental disorders, such as those of speech and communication this analogy may apply.

Many of the disorders in this category are characterized by deficits or excess in behaviors, and delay or failure to reach milestones of development (American Psychiatric Association, 2013). The behavior, while the focus of intervention, often does not adequately inform the therapeutic approach. It is essential to understand the thinking and information processing style of those who are participating in treatment (Cashin, 2005, 2008; Cashin & Barker, 2009; Cashin, Browne, Bradbury, & Mulder, 2013). Autism, for example, is characterized by a specific cognitive processing style that makes modification of treatment essential (Rotheram-Fuller & MacMullen, 2011). Intellectual disability impacts upon volume of information that can be processed and speed of processing, and this must be taken into consideration when assessing or treating a child with a developmental delay.

Behavioral disorders

Table 18.3 provides a description of common behavioral disorders and their associates symptoms including attention-deficit/hyperactivity disorder (ADHD); oppositional defiant disorder (ODD); conduct disorder (CD); and substance use disorders (SUD).

Psychiatric disorders

Table 18.4 contains a description of common psychiatric disorders seen in children and adolescents with associated symptoms, etiology, global prevalence rates and recommended treatment.

Self-harm: non-suicidal self-injury and suicide in children and adolescents

Self-harm is one of the most serious global health problems for adolescents and young adults (de Kloet et al., 2011; Muehlenkamp, Claes, Havertape, & Plener, 2012; Nock, 2012). WHO (2010b) defines self-harm as “a broader term referring to intentional self-inflicted poisoning or injury which may or may not have a fatal intention or outcome”(p. 73). Self-harm is generally divided into suicidal self-injury (SSI) and non-suicidal self-injury (NSSI) (Nock, 2012). SSI refers to suicide ideation, suicide plans, suicide attempts, and suicide death (Nock, 2012) while NSSI refers to the direct, deliberate destruction of one’s own body tissue in the absence of any intent to die (Cloutier, Martin, Kennedy, Nixon, & Muehlenkamp, 2010; Favazza, 1998; Jacobson, Muehlenkamp, Miller, & Turner, 2008; Nock, 2012). Both NSSI and suicidal behavior disorder are included as conditions for further study in the DSM-5 (APA, 2013). Muehlenkamp and colleagues (2012) conducted a systematic review of current (2005–2011) empirical studies reporting on the prevalence of NSSI and self-harm in adolescent samples across the globe and found a mean lifetime prevalence of 18.0 percent for NSSI behavior and 16.1 percent for self-harm.

NSSI is also called self-mutilation, self-injurious behaviors, or para-suicidal behaviors. The term NSSI has been formulated to distinguish self-injurious behavior from suicidal attempts because they present as separate entities with differentiable motivations (see Table 18.5) (Cloutier et al., 2010; Jacobson et al., 2008; Muehlenkamp, 2005; Nock & Kessler, 2006). Nock and Kessler (2006) reported that the US prevalence of suicide attempts decreased from 4.6 percent to 2.7 percent after a reanalysis of data from the National Comorbidity Study when intent to die was required as prerequisite for a suicidal attempt. However, it is important to note that there are youngsters who engage in both SSI and NSSI behaviors (Andover, Morris, Wren, & Bruzzese, 2012; Cloutier et al., 2010; Jacobson et al., 2008; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). Moreover, NSSI is a risk factor for suicide attempts (Andover et al., 2012; Nock, et al., 2006; Plener, Libal, Keller, Fegert, & Muehlenkamp, 2009) and 70 percent of adolescents who self-injure have at least one suicide attempt (Nock et al., 2006). Global suicide and self-harm behaviors in youth are addressed further in Chapter 12.

The incidence of suicide is rare before puberty, but becomes increasingly frequent through adolescence (Dervic, Brent, & Oquendo, 2008). In the 15–19-year-old age category, the second leading cause of death is suicide (Patton et al., 2009; WHO, 2013). Mental disorders or behavioral challenges have been identified as a root cause in 90 percent of youth death by suicide (Bridge, Goldstein, & Brent, 2006; WHO, 2006), and the most common links with suicide attempts are major depressive disorder (MDD) (Jacobson et al., 2008), anxiety disorder, PTSD, disruptive behavior disorders and substance use disorder (Chartrand, Sareen, Toews, & Bolton, 2012). Teens engaged in NSSI also show similar patterns of psychiatric disorders, including high rates of MDD, PTSD, oppositional defiant disorder, and substance use disorder (Nock et al., 2006; Nock & Kessler, 2006). Additionally, NSSI is one of the hallmark symptoms of borderline personality disorder (BPD) in the DSM-5 (APA, 2013). However, NSSI and BPD can also occur independently (In-Albon, Ruf, & Schmid, 2013). Nock and colleagues (2006) confirmed that only about 50 percent of those who engage in NSSI suffer from BPD. Table 18.5 contains a comparison between non-suicidal self-injurious behaviors and suicidal self-injurious behaviors.

Taliaferro and Muehlenkamp (2014) analyzed the data from the 2010 Minnesota Student Survey to identify risk factors associated with suicidal ideation and suicide attempts among adolescents. The risk factors included childhood physical and sexual abuse, parental substance abuse, cultural taboo about same-sex sexual attraction or experience, weight dissatisfaction and maladaptive dieting behavior, alcohol and other drug use, depression, anxiety disorders, hopelessness, involvement in bullying, running away from home, dating violence, physical fighting, self-injury, physical or mental health problems, and chronic family dysfunction or violence (Taliaferro & Muehlenkamp, 2014). They also identified protective factors against suicidal ideation or behavior among youth: parent connectedness, school engagement, involvement in certain extracurricular activities particularly sports, academic achievement, close supportive friendships, and connections to non-parental adults (Taliaferro & Muehlenkamp, 2014).

Mental health promotion strategies and evidence-based prevention programs

Mental health promotion refers to actions undertaken to improve conditions and environments as a means of supporting individual competence, mental health and well-being. The focus is on identifying and fostering strengths and supporting community assets that can then serve as resources to further promote overall health (Kobau et al., 2011), with less focus on illness and pathology. Mental health promotion strategies must address and work to correct the social determinant of health factors that impede mental health and overall well-being. Positive psychology focuses on empowerment strategies, positive attributes and ways in which individuals and communities can thrive. The WHO Global School Health Initiative developed in 1995 supports school environments that strengthen their capacity to develop healthy settings for living, learning and working. These schools focus on caring for self and others, healthy decision-making, strive to shape health related behaviors, develop and adhere to policies supporting equity, peace, social justice, and stability.

Mental Health: A Report of the Surgeon General (US Department of Health and Human Services, 1999) highlighted the importance of preventive intervention as a central activity for the improvement of children’s mental health. Childhood is a critical time for preventing mental disorders since there is a high degree of continuity between child disorders and those in adulthood (Klasen & Crombag, 2013; McDougall, 2010). Thus, it is pivotal to intervene early in a child’s life in order to prevent or reduce the likelihood of long-term impairment (McDougall, 2010; SAMHSA, 2007).

Mental health promotion strategies

As discussed in the previous section, exposure to risk factors and lack of protective factors will increase prevalence of mental health challenges. Preventive intervention in child mental health must be multifaceted, targeting both individual and community dynamics and structures that influence healthy psychological development in children. The goal would be to develop and support appropriate resources that would then promote capacity, foster resilience, and increase overall effectiveness of protective factors (Manikam, 2002; Nurcombe, 2007; Shea & Shern, 2011). Timely and effective interventions will reduce the burden of mental health disorders on children and their family, and also reduce the costs to health systems and communities (Catalano et al., 2012; Hahlweg, Heinrichs, Kuschel, Bertram, & Naumann, 2010; SAMHSA, 2007).

Preventive health care interventions are generally classified as primary, secondary, and tertiary as proposed by the Commission on Chronic Illnesses (CCI) (1957). Primary prevention refers to interventions targeting the general population to prevent future health problems and involves education, while secondary prevention involves screening and prompt intervention for those who are beginning to show signs of difficulty by early identification and effective treatment (CCI, 1957). Tertiary prevention aims to reduce the severity of the impairment associated with an existing disorder, support rehabilitation success, prevent relapse, and achieve the highest level of functioning (CCI, 1957).

The Institute of Medicine (IOM) (1994) has recognized issues in applying this traditional classification to mental health and has redefined intervention phases into prevention, treatment, and maintenance. In order to describe the different service needs in the prevention phase, IOM has adapted the framework of Gordon (Gordon, 1987), which divides preventive intervention strategies as universal, selective, and indicated, based on the population groups to whom interventions are directed. Universal prevention targets the entire population of a particular area, whereas selective intervention targets specific groups or individuals whose risk of developing a mental disorder is significantly higher than average due to exposure to some risk factors (IOM, 1994). Indicated prevention involves targeting those individuals who exhibit subclinical symptoms of a disorder (IOM, 1994).

The IOM commissioned development of the framework is summarized in Figure 18.1.

Prevention phase (primary intervention)

Prevention strategies in this phase involve either universal prevention or selective prevention; both strategies target those individuals who are currently functioning normally in order to prevent future problems. Durlak, Weissberg, Dymnicki, Taylor, and Schellinger (2011) reviewed 213 school-based universal prevention programs and confirmed significant improvement in social and emotional skills, attitudes, behavior, and academic performance in children. Sometimes specific intervention strategies might be necessary to address children’s needs depending on the nature of targeted mental health issues. The prevention interventions that focus on helping children build coping skills and social competence, and also reinforcing proper parenting skills might be most effective in children regardless of the circumstances (El Din, 2004; Masten & Monn, 2015).

Figure 18.1   Reducing risks for mental disorders: frontiers for preventive intervention research, 1994

Source: Reprinted with permission by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, DC.

Parenting skills

Parenting plays a crucial role in a wide variety of child social, emotional, behavioral, and intellectual outcomes (Landry, Smith, & Swank, 2006; Shapiro, Printz & Sanders, 2008). Researchers have reported that parental attachment contributes positively to self-esteem and life satisfaction and negatively to measures of depression, anxiety, and feelings of alienation (Grant et al., 2006; Manikam, 2002). Dysfunctional parent–child interactions increase the risk of mental disorders, particularly when they are prolonged and accompanied by other adverse factors (Dodge, Coie, & Lynam, 2006). Conversely, enhanced parenting can even mitigate or buffer the adverse effects of environmental adversities on early childhood development (Domian, Baggett, Carta, Mitchell, & Larson, 2010; Leidy, Guerra, & Toro, 2010).

Therefore, it is crucial to teach parents optimal parenting skills in order to help build positive relationships with their children. Studies have shown that interventions targeted towards parenting have been efficacious in improving parental perceptions, children’s social skills and school adjustment, and also produced reductions in behavioral problems (Barlow & Stewart-Brown, 2000; Cartwright-Hatton, McNicol, & Doubleday, 2006). Parenting training is also known to promote family coping, consistency, cohesion, and use of family support networks, each of which support the development of family resilience (Masten & Monn, 2015; Webster-Stratton, 2009).

Coping and social skills

Psychosocial stress is a significant and pervasive risk factor for psychopathology in childhood. But, in reality, children need to handle a wide range of challenging social situations every day. The ways in which children cope with stress are potentially important mediators and moderators of the impact of stress on current and future adjustment and psychopathology (Compas et al., 2001). Also, a child’s ability in social interaction with his/her environment may be the best way to predict the child’s mental health (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Grossman & Liang, 2008; Gumpel, 2007). Thus, preventive mental health interventions for children may be desirable to promote the coping and social skills of children (Durlak & Wells, 1997; Greenberg, Domitrovich & Bumbarger, 2001; Spence, 2003).

Global evidence-based preventive programs

“Evidence-based prevention” can be defined as

the conscientious, explicit and judicious use of current best evidence to make decisions about interventions for individuals, communities and populations that facilitate the currently best possible outcomes in reducing the incidence of diseases and in enabling people to increase control over and to improve their health.

Additionally, Nation and colleagues (2003) have identified nine characteristics that are consistently associated with effective prevention programs: being comprehensive, using varied teaching methods, providing sufficient dosage, including theory-driven strategies, providing opportunities for positive relationships, being appropriately timed, incorporating relevant socio-cultural values and practices, integrating outcome evaluations, and involving well-trained and sensitive staff.

Most of the evidence-based mental health preventive interventions have been developed in high-income countries, such as the USA, Canada, Australia, and northern European countries (Klasen & Crombag, 2013; WHO, 2004). WHO (2004) has published Prevention of Mental Disorders: Effective interventions and Policy Options to facilitate the use of evidence-based interventions worldwide, especially for low-income countries where there is a lack of prevention knowledge in spite of enormous public mental health problems. WHO (2004) has also advised that service providers need to take into consideration cultural adaptation when they implement evidence-based programs from other countries or cultures in communities and target populations that differ from the ones that were originally developed and tested.

Klasen and Crombag (2013) have performed a systematic review of all randomized controlled trials in child and adolescent mental health in low- and middle-income countries, and have indicated that affordable and feasible interventions can be developed to improve the functioning of affected children, their families and their communities worldwide. In addition, they have found that parent training is a highly effective intervention in lessening conduct symptoms in behavioral disorders. Also, children who are exposed to war, disaster, and other traumatic experiences can be well treated in low resource settings even in unstable environments with proper interventions (Klasen & Crombag, 2013).

Fayyad and colleagues (2010) adopted the parenting skills intervention that was developed by the Integrated Services Taskforce of “the World Psychiatric Association Child Mental Health Presidential Programme” in order to check the feasibility of dissemination of the evidence-based intervention in a developing country. The program was delivered to 87 mothers of children with behavior problems in Lebanon by social and health workers with little or no mental health background who were trained for this program over four half-day sessions. This pilot project revealed that the intervention was effective in decreasing both the abnormal range of the children’s behaviors from 54.4 percent to 19.7 percent, and mothers’ use of severe corporal punishment from 40.2 percent to 6.1 percent.

Patel and colleagues (2007) have proposed “a population-based, youth focused model” to improve the range of affordable and feasible interventions to youth in both developing and developed countries. The model recommends integrating youth mental health programs into all existing youth programs, including general health, education, and welfare programs, since those programs are less stigmatized and more accessible to young people and can provide youth-friendly services under the same location (Patel et al., 2007).

The following four preventive mental health programs are cited by WHO (2004) as global exemplary evidence-based prevention interventions. These are mostly a universal prevention or a selective prevention, which mental health nurses who work in community and school settings can utilize.

Low educational attainment and evidence-based interventions

Low educational attainment is a worldwide problem, especially in developing countries. The Millennium Developmental Goals Report 2013 (United Nations (UN), 2013) has set one of its major global goals as achieving universal primary education in order to enhance proper education and prevent poor academic performance in children. This report indicates that 57 million children globally are still denied their right to primary education and more than half of these children live in sub-Saharan Africa. It further reports that 123 million youths aged 15 to 24 lack basic reading and writing skills and 61 percent of them are young women (UN, 2013). Moreover, in lower-income countries, only 37 percent of adolescents complete lower secondary education and the rate is as low as 14 percent for the poorest (UNESCO, 2014). Even high-income countries that provide free or mandatory secondary education still have problems. In Europe, about 14 percent of all 18-to 24-year-olds either complete a low level of education or end their education without a certificate, which are of little use in the labor market (Theunissen, Griensven, van Verdonk, Feron, & Bosma, 2012). A 2009 survey showed that 8 percent of 16-to 24-year-olds in the US did not have a high school degree and were not enrolled in school (Aud et al., 2011).

Low educational attainment is described as children who do not enroll, do not progress, or drop out (Petrosino, Morgan, Fronius, Tanner-Smith, & Boruch, 2015), and poverty is known to be a key factor of this phenomena (UN, 2013). Children from the poorest households are at least three times more likely to be out of school than children from the richest households in developing countries (UN, 2013). It is common for children to work to earn money to support their family or to stay home to take care of younger siblings. In some cultures, girls are not encouraged to pursue education and are expected to help out at home. Additionally, the cost of schooling, poor school infrastructure, teacher shortages, and safety and sanitation problems are some other factors that impede children’s education in developing countries (Birdsall, Levine & Ibrahim, 2005). Meanwhile, variables associated with low educational attainment in developed countries include poor or single-parent households, minority status, poor academic performance, school disengagement, dissatisfaction with teachers, peer rejection, chaotic school environment, alcohol and substance abuse, adolescent pregnancy, mental illnesses, low parental expectation, and family disruption (El Din, 2004; Fan & Wolters, 2014; Graeff-Martins et al., 2007; Nurcombe, 2007).

Low educational attainment has long-lasting negative consequences for individuals, families, and communities, as indicated by low earnings, more dependence on public assistance, poor health outcomes, life-dissatisfaction, social alienation, depression, alcohol and drug abuse, criminal activities, and higher chance of an intergenerational cycle (Fall & Roberts, 2012; Flisher, Townsend, Chikobvu, Lombard, & King, 2010; Henry, Knight, & Thornberry, 2012). On the other hand, education can help individuals escape poverty, improve health outcomes, and stop poverty from being passed down through the generations (Petrosino et al., 2015; UNESCO, 2014).

Due to the disparate and varied reasons for low educational attainment, there may not be one common solution to this problem. However, regardless of the cause of low educational attainment, early intervention may be crucial. Increased access to schooling is a necessary first step towards universal primary education in developing countries (UN, 2013). According to Petrosino and colleagues (2015), who have done a systematic review of impact studies on school enrollment interventions in developing countries, the interventions with the largest average effects are the ones that focus on improving school or community infrastructures, such as building new schools, repairing schools, and improving roads/access to schools. These developments increase student enrollment, student attendance and academic progress, as well as decrease school dropout (Petrosino et al., 2015). Graeff-Martins and colleagues (2006) have assessed the feasibility and initial efficacy of a package of universal preventive intervention designed to reduce school dropout in developing countries. This intervention was implemented in a city public school in Brazil and yielded significant effects in dropout and absenteeism (Graeff-Martins et al., 2006). The package consisted of two workshops with teachers, five letters to parents, three meetings with parents and school, a telephone helpline, 1-day cognitive intervention and a mental health assessment with possible referral to resources available in the community for students absent more than 10 days (Graeff-Martins et al., 2006). In Honduras, a number of middle-school alternative programs have been implemented to expand post-primary school coverage for at-risk youngsters who live in rural and urban areas. These programs have been successful in reaching a vulnerable population in the country, although dropout rates are generally high (Marshall et al., 2014).

In developed countries, most of the intervention programs are school-based programs, which aim to prevent school dropout and absenteeism. It is reported that the role of teachers as tutor-counselors is the most crucial and has a significant impact on school success, engagement, and educational achievement of youngsters (Graeff-Martins et al., 2007). Also, students and families, who feel marginalized in their relations with teachers and peers, need further support to connect at school and engage with students’ learning (Christenson & Thurlow, 2004; Graeff-Martins et al., 2007). Tanner-Smith and Wilson (2013) report that dropout programs have generally been shown to be effective at reducing school dropout, and the relationship between absenteeism and later school dropout is well-established based on their findings from a systematic review and meta-analysis of literature on school dropout prevention and intervention programs. The most frequently used dropout intervention modalities can be classified as school/class restructuring, supplemental academic training, mentoring counseling, alternative school, cognitive behavioral/skills training, attendance monitoring/financial rewards, vocational/employment oriented, and multi-service packages (Tanner-Smith & Wilson, 2013).

The US Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA, 2007) have introduced “Reconnecting Youth (RY)” as an effective evidence-based dropout prevention program. RY is a selective school-based program for youth in ninth through twelfth grade (ages 14 to 18), who are at risk for school dropout. The central program goals are to decrease drug involvement, increase school performance and decrease emotional distress. It uses a partnership model involving peers, school personnel, and parents and caregivers. Since RY was developed in 1985 by Leona Eggert, child/adolescent psychosocial nurse specialist, and Liela Nichola in the United States, it has been implemented in all 50 states as well as internationally (e.g., in Canada, Germany, Malaysia, Russia, and Spain) to reach hundreds of thousands of youth (SAMHSA, 2007).

Role for nurses

Mental Health Atlas 2011(WHO, 2011) reports that nurses represent the largest professional group working in the mental health field worldwide, with the median rate of nurses in this sector at 5.8 per 100,000 population. This is greater than the rate of all other mental health workers combined. In particular, nurses have been primary providers in delivering necessary care to children with mental health challenges in most low- and middle-income countries where mental health professionals are scarce (WHO, 2007). In some developed countries, psychiatric/mental health nurses have expanded their roles, with adequate educational preparation, to advanced functioning, which includes diagnosing, prescribing medication, and providing various types of supportive therapies including brief, trauma-focused, group, and individual to children in need. This model needs to be applied to and scaled up for use in low- and middle-income environments that are resource poor.

Therefore, it will be greatly beneficial to develop and offer educational opportunities to nurses and expand their roles accordingly in order to provide timely and effective services to children with mental and behavioral disorders and their families. Above all, nurses need to be recognized as essential and untapped human resources, capable of providing these crucial services.

Conclusion

About 20 percent of children suffer from mental disorders worldwide, accounting for a significant portion of the global burden of disease (Belfer & Nurcombe, 2007; Kieling et al., 2011). Burden involves higher rates of health care utilization, necessary educational accommodation, and potential burden to both the criminal justice and social service systems (Belfer, 2008; Merikangas et al., 2009). In addition, mental health challenges and behavioral symptoms cause enormous burden to children and their families. In low-income communities resources are insufficient, inequitably distributed and poorly used, contributing to a 90 percent treatment gap (Malhotra & Padhy, 2015). If untreated, childhood difficulties persist into adulthood resulting in poor quality of life, erosion of self-esteem and lost productivity.

Engaging in mental health promotion and prevention efforts is a necessary component when addressing barriers to human flourishing associated with the social determinants of health. Supportive resources for children include parents, teachers, nurses, and primary care providers, but ideally must be extended to many other groups involved in nurturing young people where they work, play, and learn. The specialist child and adolescent mental health nurse clinician has a strong role to play in education, policy development, and promotion of mental health literacy within communities. In addition nurses can use their expertise when conducting comprehensive assessments and providing evidence-based treatment within a culturally aware, respectful, and inclusive framework.