The Forgotten Child

About 10% to 20% of children and adolescents suffer from some kind of mental health disorder. Many adult psychiatric disorders have their origin in childhood and adolescence.¹

Inadequate or delayed treatment is associated not only with personal suffering, compromised normal emotional and social development, and impairment in multiple domains including education, occupation, interpersonal relationships and self-esteem, but also family and carer stress. Yu et al²draw our attention to the mental health of mothers whose preschool children are diagnosed with autism spectrum disorder.

Provision of a child mental health service in Hong Kong is shared by the Hospital Authority, Department of Health, the educational system, Social Welfare Department, non-governmental organisations, and private sectors. The worldwide trend of rising service demand, increasing public expectations and resource limitations is also noted in Hong Kong.

Only some of those in need receive proper mental health treatment and care.^3,4The underlying reasons vary in different settings. Examples include underdiagnosis, misdiagnosis, inaccessibility of service, poorly coordinated and fragmented services, lack of expertise, lack of public (or professional) awareness, and other obstacles to service seeking, such as stigmatisation towards mental problems and mental health care.⁵

Different strategies have been proposed and initiatives implemented in an attempt to tackle these challenges. Fung et al⁶describe and discuss the results of a knowledge contact–based anti-stigma campaign in a Chinese society.

While mental health problems in some patients are more eye-catching, such as the patient described by Che⁷who readily caught the attention of mental health professionals, others may present with more subtle symptoms. There is always an important but forgotten group of children and adolescents who are in need of more attention and proper mental health assessment and / or intervention but sadly have little access to the existing system. Some are ‘at risk’ of future development of psychopathology and are simply not being recognised or ignored. Some are hesitant or reluctant to seek help because they fear being stigmatised. Some fail to reach the service ‘threshold’ for referral. Others simply fall through the cracks because they fulfil nobody’s criteria for help.

If we agree that we should identify this group of children who are being ‘forgotten’, where should we invest our effort? It is well documented that mental disorders run in families. Genetic factors play a significant aetiological role in many mental health problems.⁸Siblings of an affected child are at increased risk of psychopathology due to a complex interplay of gene-environmental factors.⁹

Chan and Lai¹⁰explore the psychological adjustment of siblings of children with autism spectrum disorder in Hong Kong. Children of parents who had psychopathologies are another vulnerable group.¹¹Peers of suicide completers and attempters are at risk of psychiatric disturbance and suicidal behaviour.¹²

Those who have been referred to the mental health service, but subsequently disappear from the system may be a group who deserve extra attention. There is always a group who (the affected child and / or parents) are inadequately motivated to seek intervention or help, and this could be due to multiple different reasons. How much additional effort, given the limited resources (e.g. long waiting list for initial child psychiatric outpatient assessment and long waiting list for psychosocial intervention), are we willing to make to reach out to and engage this group? The dilemma is more obvious for non-priority cases who previously received ‘conventional intervention’ (e.g. no imminent risk of aggression, suicide, or child abuse).

CAMHS (Child and Adolescent Mental Health Service) traditionally offers service for those at the severe end of the spectrum, through referral from primary and secondary mental health workers. Thanks to medical advances we now have more and more evidence-based intervention but there is now a pressing need for us to revisit the questions: What is the most suitable service model that adapts to local needs? Should our service cover the whole spectrum of mental health concerns or merely focus on the severe end of the spectrum? How to turn that into sustainable health care practice? How to mobilise and efficiently coordinate the various child mental health professionals and sectors? How much emphasis should be placed on primary, secondary, and tertiary intervention, given the limited resources? Are we prepared to reach out to the forgotten group?

It is understandable that different service providers and stakeholders have their own philosophies, prioritisation of focus, and work culture. In order to achieve seamless integration, efficient implementation and good coordination of timely comprehensive assessment and evidence-based intervention for those with mental health needs across the spectrum, the government should take the lead to work with relevant parties for better provision of information, awareness, and education about mental health, better provision of service for the currently underserved group, and better provision of social, financial, and legal protection for this disadvantaged group as well as better social support.¹³

Completion in one step is unrealistic. It is hoped that a concerted effort by the various parties will better safeguard this forgotten group of children and adolescents from the risk and suffering due to mental health problems.

Chun-pan Tang (email: tangcp@ha.org.hk)

Consultant, Kwai Chung Hospital, Hong Kong SAR, China

References

Kessler RC, Amminger GP, Aguilar-Gaxiola S, Alonso J, Lee S, Ustün TB. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry 2007;20:359-64.
Yu YW, Chung KH, Lee YK, Lam WC, Yiu MG. Prevalence of maternal affective disorders in Chinese mothers of preschool children with autism spectrum disorders. East Asian Arch Psychiatry 2016;26:121-8.
Kataoka SH, Zhang L, Wells KB. Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status. Am J Psychiatry 2002;159:1548-55.
Lam LC, Wong CS, Wang MJ, Chan WC, Chen EY, Ng RM, et al. Prevalence, psychosocial correlates and service utilization of depressive and anxiety disorders in Hong Kong: the Hong Kong Mental Morbidity Survey (HKMMS). Soc Psychiatry Psychiatr Epidemiol 2015;50:1379-88.
Rüsch N, Corrigan PW, Wassel A, Michaels P, Larson JE, Olschewski M, et al. Self-stigma, group identification, perceived legitimacy of discrimination and mental health service use. Br J Psychiatry 2009;195:551-2.
Fung E, Lo TL, Chan RW, Woo FC, Ma CW, Mak BS. Outcome of a knowledge contact–based anti-stigma programme in adolescents and adults in the Chinese population. East Asian Arch Psychiatry 2016;26:129-36.
Che KI. Recurrent psychotic episodes with a near-monthly cycle. East Asian Arch Psychiatry 2016;26:137-40.
Neumann A, Pappa I, Lahey BB, Verhulst FC, Medina-Gomez C, Jaddoe VW, et al. Single nucleotide polymorphism heritability of a general psychopathology factor in children. J Am Acad Child Adolesc Psychiatry 2016;55:1038-45.e4.
Mandy W, Lai MC. Annual Research Review: The role of the environment in the developmental psychopathology of autism spectrum condition. J Child Psychol Psychiatry 2016;57:271-92.
Chan JY, Lai KY. Psychological adjustment of siblings of children with autism spectrum disorder in Hong Kong. East Asian Arch Psychiatry 2016;26:141-7.
Geulayov G, Metcalfe C, Heron J, Kidger J, Gunnell D. Parental suicide attempt and offspring self-harm and suicidal thoughts: Results from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. J Am Acad Child Adolesc Psychiatry 2014;53:509-17.e2.
Ho TP, Leung PW, Hung SF, Lee CC, Tang CP. The mental health of the peers of suicide completers and attempters. J Child Psychol Psychiatry 2000;41:301-8.
Investing in mental health: evidence for action. Geneva: World Health Organization; 2013.

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