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Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Challenges in international collaboration in child and adolescent psychiatry a
Hesham M Hamoda & Myron L Belfer
a
a
Children's Hospital Global Partnerships in Psychiatry, Children's Hospital Boston and Harvard, Medical School , 300 Longwood Ave, Boston, MA, 02115, USA Published online: 15 Nov 2010.
To cite this article: Hesham M Hamoda & Myron L Belfer (2010) Challenges in international collaboration in child and adolescent psychiatry, Journal of Child & Adolescent Mental Health, 22:2, 83-89, DOI: 10.2989/17280583.2010.528577 To link to this article: http://dx.doi.org/10.2989/17280583.2010.528577
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
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Journal of Child and Adolescent Mental Health 2010, 22(2): 83–89 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/17280583.2010.528577
Commentary Challenges in international collaboration in child and adolescent psychiatry
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Hesham M Hamoda* and Myron L Belfer Children’s Hospital Global Partnerships in Psychiatry, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA * Corresponding author, e-mail: [email protected] International collaboration in child and adolescent psychiatry has historically been weak and fragmented. The field has also lagged in developing remedies for improving collaboration. This article identifies barriers to successful collaboration and examines problems in the areas of finance, professional development, knowledge dissemination, professional organisations, public policy and the political environment, priority setting, nomenclature, as well as ethical challenges. The article then identifies some promising initiatives and proposes solutions to improve international collaboration in child and adolescent mental health.
Introduction While there are many obstacles to collaboration in child mental health in developed countries, the obstacles to productive collaboration across low and middle income (LAMI) countries and between LAMI and developed countries are daunting. In an era where the dissemination of evidencebased practices is essential, overcoming barriers for collaboration is of paramount importance. Controversial aspects of international collaboration need to be identified. Collaboration needs to be guided by the immediate and long-term benefits for the populations studied, and be rigorous enough to be valuable as research. The global health scene, including that of global child mental health is characterised by fragmentation, lack of coordination and even confusion. Many initiatives in global health have been criticised as being narrowly focused on specific diseases rather than systems-wide strengthening (vertical rather than horizontal), tend to be ‘top-down’ in nature and are largely driven by donor agendas rather than the country’s own needs and priorities (Sridhar, Khagram and Pang 2009). Many of the initiatives lack mechanisms of accountability, transparency and evaluation (Sridhar and Batniji 2008). A review of the research literature reveals that the rigor of cross-cultural research is often less than would be expected (Saxena et al. 2006) in part, because the research has been conducted with an apparent lack of awareness of contemporary findings in others settings and inappropriate use of randomised controlled trials (RCT). It is now clear that RCTs have major shortcomings when trying to implement findings in real life settings where contextual factors and co-morbidities impinge on programme design and implementation (Friedman and O’Reilly1997). Child mental health research lags in identifying ways in which international collaboration can be improved. The issues are particularly crucial for child psychiatry given the shortage of professionals
Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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with research training and the global demand for implementation of evidence-based programmes for children affected by disasters, war and social upheaval. This article identifies barriers to successful collaboration by examining problematic areas and proposes solutions to improving international collaboration in child mental health. We note that considerable variability exists both within and between developing and developed nations, nevertheless, we tried to identify some general themes that may impede collaborative efforts.
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Obstacles to collaboration The obstacles to collaboration internationally are understandable, but can be overcome with careful planning, development of trusting relationships and attention to seemingly mundane impediments, such as, language, financial transactions, International Review Board approvals, among others. Particular to child mental health is the paucity of well trained child mental health professionals in developing countries who can interact with each other and with governments. This limitation is key for the dissemination of the unique knowledge associated with child mental health and undermines the development of programmes and policies. Language differences impede understanding. Even within regions presumed to be using the same or similar language, differences in understanding can be profound. For instance, in the Eastern Mediterranean region it is often easier to use Classical Arabic or even English or French as the common communication language than to attempt the reconciliation of meaning using different Arabic dialects. Attempts to identify major international child mental health collaborative efforts that meaningfully involved colleagues from developing countries yield few results, and fewer still in the peer reviewed literature. Models for successful collaboration are difficult to find. An exception has been the standardization of screening instruments and measures of psychopathology where many studies have been conducted. However, there are methodological challenges associated with applying Western instruments in populations that differ dramatically than those for which they were developed (Hollifield et al. 2002). These international studies more commonly investigate reliability rather than validity across cultural groups and are weak on cultural relevance (Betancourt et al. 2009). The World Health Organization (WHO) can provide access to resources, but usually is not a source of major financial support. The WHO can ease many political barriers that would otherwise be insurmountable. Some have suggested that ‘the only organization with the political credibility to compel cooperative thinking is the WHO’ (Garrett 2007: 14–18). WHO-supported model programmes can also provide a common frame of reference for programme or research collaboration. It can and should provide the incentive and support for international collaboration on a broader scale. The WHO ‘is uniquely positioned to provide this leadership by virtue of its role in setting evidence based norms on technical and policy matters, highlighting best practices that improve health globally, and monitoring and coordinating action to address current and emerging global health threats’ (Institute of Medicine 2009: 28). For instance, the WHO Suicide Prevention Program, SUPRE-MISS, involved countries from all WHO regions in an elaborate research protocol. In recent years the WHO Assessment Instrument for Mental Health Systems (AIMS) project, the WHO Atlas initiatives and the current WHO Mental Health Gap Action Programme (mhGAP) programme has fostered meaningful data gathering and provided a basis for collaboration while not in themselves representing crosscountry collaboration. Obstacles to collaboration not only exist at the international level, but also nationally. Within countries, almost universally, there is competition in the academic sector. Rivalries and distrust can impede collaboration. Finding the means for research and programmatic governance can ease the distrust. Care needs to be taken to ensure constant communication among the involved parties. Within country economic disparities lead to widely differing levels of service delivery. Unfortunately, the economic disparity also leads professionals to migrate to centers where financial support and community can provide for a better life.
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Problematic areas for collaboration Finance Funding is problematic everywhere. Specific concerns arise when funding comes with restrictions that limit the development of programmes or research that is culturally relevant and respects the rights of the child and family. The mobilisation of financial resources for complex international multi-site trials for clinical interventions has been very difficult. The same is not true for research instrument validation studies that have strong support from the originator/ sponsor (Rescorla et al. 2007). Governments appear reluctant to ‘subsidise’ other countries by funding research projects abroad. Non-governmental funders of international collaborations require accountability that is often difficult to achieve. Pharmaceutical companies have been supportive of international collaboration, but often with a narrower focus on the efficacy and effectiveness of a particular medication for a particular disorder. Major foundations often request a North-South partnership which imposes constraints on potential collaborative efforts among more than two or three collaborators. The absence of identifiable child and adolescent mental health budgets in LAMI countries and the episodic nature of NGO funding undermine stable collaboration. The transfer of money between countries is often very difficult and the taxes imposed (direct and indirect) may erode the value of any grant. While international meetings provide an important venue for sharing information, research results, and networking, funding for such meetings is still highly dependent on pharmaceutical companies’ support. Professional development Besides adequate funding, collaborative efforts in child and adolescent mental health need trained human resources. Collaboration in the realm of professional development and developing human capital offer a different set of challenges. Child psychiatrists in the European Union seek a uniform set of training standards across Europe through the European Union of Medical Specialists (Karibekiroglu et al. 2006). While it is possible to articulate a clear set of standards, it requires considerable political agility to get standards adopted, and overcome resistance in recognising child psychiatry as an independent discipline. Additionally opportunities for clinical training for young child and adolescent psychiatrists from developing countries in Western institutions are limited, with many familiar barriers: culture, language, finances, licensure, and accreditation. Amongst the few applicants able to overcome these obstacles and receive training in Western countries, even fewer return to their countries of origin, which adds to the ‘brain drain’ phenomenon. For those who do return, there are questions about the relevance of their training when they practice in environments where basic mental health services and medications are lacking. The problems with collaborative efforts do not rest solely with the less developed countries. It is difficult to secure time away from clinical work or research to pursue overseas collaborative work in a sustained way, and there are few financial incentives to address this. Interestingly, psychology graduate students and post-doctoral fellows have more support to pursue research abroad and thus we see in this generation the majority of pediatric mental health research being carried out by non-child psychiatrists. Knowledge dissemination Researchers from both developed and developing countries face common challenges that require them to acquire skills in research methodology, grant writing, fundraising and basic statistical knowledge. There is however a set of challenges that are unique to researchers from developing countries including writing in English and choosing appropriate journals for their submissions (Ehrlich, Jefferson-Lensky and Plener 2007). Earlier the issue of language was mentioned as a barrier to collaboration. A second important language issue is the use of the language of scientific writing. The training of collaborators in this domain may not be equivalent. There is a learning
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gradient for some to be able to understand the complexity of protocols, the meaning of particular interventions, and how to communicate their research findings. A study by Patel and Kim reviewed original research contributions from LAMI countries published over a three-year period in the six highest-impact general psychiatry journals. The study found that only 3.7% of published research emerges from these less affluent countries, which account for over 80% of the global population (Patel and Kim 2007). The authors proposed several explanations for their findings including the overall low proportion of submissions from LAMI countries, the possibility that authors from these countries might be choosing local journals for their research, and the low research output and research capacity in these countries. In part, this lack of capacity is associated with a lack of psychiatrists. In addition the authors suggested other potential explanations on why articles from LAMI countries are more likely to be rejected; the quality of the research and editorial and reviewers attitudes towards articles from these countries, a view shared by others (Tyrer 2005). Collaboration among professional organisations Professional associations that are international in scope have existed for generations. In the past, rivalries around areas of clinical concern or the composition of groups led to a decrease in the potential for mutual advocacy and advancement of the field. Now, the leadership of these professional organisations has recognised the overwhelming need to act in concert for effective advocacy and thus many have joined in forming a Global Consortium to advance education and advocacy. The Consortium includes the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP), World Association for Infant Mental Health, the International Association for Adolescent Psychiatry and Psychology, the World Federation for Mental Health and the International Association for Child Mental Health in Schools. This marks a significant departure from the fragmentation of the past, though there are still tensions in the rivalries between child-focused clinical disciplines and adherents to particular clinical philosophies. Public policy and the political environment Research and programme policy development at the level of national governments is lagging worldwide. This hampers collaboration because there is no reference for how to proceed, what are the limits of liability, and what the sanctions are for research or novel clinical interventions. With the development of more interventions in developing countries this is an area of great interest and discussion. International policy is even less evident. The United Nation Convention on the Rights of the Child provides some guidance at the extremes but does not provide specific guidance for research or clinical intervention (the USA and Somalia are the only two countries that have not ratified this convention). In addition, what may be acceptable in one country or region may not be acceptable in another. For instance, the place of children in society may differ and this leads to a lessening or heightening of concern to provide care or to expose children to interventions. The failure to mobilise political will is key to the observed lack of development of public policy for child mental health. As for any political process mobilising resources, forming alliances and political activism will be essential to put child mental health on the political agenda at both the national and global levels. Differing agendas There may be legitimate differences in the research interests and priorities between developing and developed nations. For example, researchers from developing countries may be in urgent need to conduct epidemiological and culturally specific research, whereas researchers from Western nations typically have resources that allow for other types of studies including sophisticated, biologically-based research. A recent study examining mental health research priorities in LAMI countries identified epidemiology, health systems and social science as the highest priorities in mental health research (Sharan et al. 2009). Once again, a major guiding factor in collaboration needs to be a clear delineation of expectations, an understanding of how resources can be shared to achieve these goals, and an open forum for discussing the possible barriers along the way.
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Nomenclature A major contemporary challenge for international research, as it relates to epidemiology and clinical intervention, is the need to reconcile the common classifications of mental illness. ICD-10 and DSM-IV, even with differing criteria, are now widely recognised as being inadequate for the diagnosis of childhood mental disorders, especially because they lack adequate inclusion of knowledge about developmental processes and cultural variations. This leads to problems in research generalisation as well as designing interventions, and will likely require a classification system that would be more dimensional and would meaningfully integrate cultural variables. Ethical challenges The risk of exploitation, the imposition of Western values, and the distortion of clinical findings could and have permeated the partnerships between Western researchers and those in developing nations (Osrin et al. 2009, Schuklek 2000, World Medical Association 2001). Not all centers in developing countries have institutional review boards and ethical standards for research may vary. Western scientific research standards and scientific journals require that such safeguards exist. Ethical issues also arise when research on children and adolescents is conducted in developing countries where there are no or few child psychiatrists and in situations where studied populations will not benefit directly from the research findings. Ways forward Despite the numerous challenges there are precedents for successful international collaboration. The World Psychiatric Association (WPA), the IACAPAP and WHO developed a Global Child and Adolescent Mental Health Program during the WPA presidency of Ahmed Okasha (Remschmidt et al. 2007). With sufficient financial resources, international leadership sensitive to the particular challenges facing transnational collaboration, and the involvement of knowledgeable professionals, two global collaborative research projects were initiated, including a study of the impact of school drop-out in Russia, Brazil, and Egypt, and the development of an awareness manual addressing stigma related to children and adolescents with mental disorders, which was based on data gathered from nine developed and developing countries (Hoven et al. 2008). Earls and colleagues demonstrated a multilevel collaborative effort with the goal of enhancing personal agency and community efficacy (Earls, Raviola and Carlson 2008). Among psychiatric journals there is an increasing awareness of the importance of supporting publication of research from LAMI countries. For example, Peter Tyrer, the editor of the British Journal of Psychiatry notes that ‘this is more than a mere question of equity; if we do not acknowledge the contribution of the 90% adequately [referring to developing countries that constitute 90% of the world], we may lose essential elements of knowledge in our attempts to develop a complete picture of the etiology, course and management of mental disorders’. Tyrer recommended increasing research capacity and manuscript development skills as a remedy to this problem (Tyrer 2005: 1–3). He also noted that a small number of journals, including the British Journal of Psychiatry, promote a minor form of positive discrimination, asking referees to be more generous in assessing articles from the 90% under-represented countries. In 2004, The WHO and the editors of scientific journals issued a consensus statement expressing concern about the wide gap in research evidence, and emphasised the role of scientific journals in promoting research from LAMI countries (WHO and Joint Editors 2004). This is an important step, yet the effectiveness of these initiatives is still to be evaluated. Clinicians should seek international collaborations that are not limited to research. Establishing clinical collaborative networks through mentorship of clinicians from developing nations, teaching courses, giving presentations, and consulting on difficult cases are all activities individual clinicians could engage in. Considering longitudinal involvement with one country could allow for a better understanding of the unique challenges in that country and provide for a more meaningful collaboration.
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Finally, innovative programmes for clinicians from developing nations for short term clinical placements in Western institutions could also provide unique opportunities particularly if they focus on teaching skills that are applicable in developing countries. An example is the international child mental health training programme at Children’s Hospital of Boston’s Department of Psychiatry that is co-sponsored with the Department of Social Medicine at the Harvard Medical School. The programme provides one to three month observer participation in clinical teaching at Children’s Hospital and participation in didactics at the Department of Global Health and Social Medicine at the Harvard Medical School. The programme focuses on skills that could be used in developing countries and is not intended for clinicians who are planning to practice in the USA.
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Conclusion With the shift in the emphasis in public health from infectious diseases to non-communicable diseases, as well as the increase in the acceptance of seeking mental health treatment in many communities, the opportunities for our field are tremendous. The current generation of child psychiatrists and other child mental health professionals have embarked on new collaborations less burdened by past rivalries or ideological constraints. The momentum is present within the groups to sustain clinical, research and training efforts and to provide mentorship. This encouraging development bodes well for future collaborations that will overcome barriers to communication, build natural alliances and seek resources to expand efforts on behalf of children and adolescents across the globe. Ackowledgement — During the time the manuscript was revised, Dr Hamoda was supported by a DupontWarren Fellowship Award from the Harvard Medical School Department of Psychiatry. The authors report no conflicts of interest to disclose relevant to the content of this article. The authors alone are responsible for the content and writing of this article. It has been presented in part at the International Association of Child and Adolescent Psychiatry and Allied Professions Congress in Beijing, China, June 2010.
References Betancourt TS, Bass J, Borisova I, Neugebauer R, Speelman L, Onyango G and Bolton P (2009) Assessing local instrument reliability and validity: A field-based example from Northern Uganda. Social Psychiatry and Psychiatric Epidemiology 44: 685–692 Earls F, Raviola GJ and Carlson M (2008) Promoting child and adolescent mental health in the context of the HIV/AIDS pandemic with a focus on sub-Saharan Africa. The Journal of Child Psychology and Psychiatry 49: 295–312 Ehrlich S, Jefferson-Lensky N and Plener PL (2007) Worldwide research networks for young child and adolescent psychiatrists: How can we help each other help children? European Child and Adolescent Psychiatry 16: 525–526 Friedman SR and O’Reilly K (1997) Sociocultural interventions at the community level. AIDS 11(Suppl. A): S201–S208 Garrett L (2007) The challenge of global health. Foreign Affairs 86: 14–38 Hollifield M, Warner TD, Lian N, Krakow B, Jenkins JH, Kesler J, Stevenson J and Westermeyer J (2002) Measuring trauma and health status in refugees: A critical review. The Journal of the American Medical Association 288: 611–621 Hoven CW, Doan T, Musa GJ, Jaliashvili T, Duarte CS, Ovuga E, Ismayilov F, Rohde LA, Dmitrieva T, Du Y, Yeghiyan M, Din AS, Apter A, Mandell DJ and WPA Awarness Task Force (2008) World-wide child and adolescent mental health begins with awareness: a preliminary assessment in nine countries. International Review of Psychiatry 20: 261–270 Institute of Medicine (2009) The US Commitment to Global Health: Recommendations for the Administration. Washington: National Academic Press. Available at: http://www.nap.edu/catalog/12506.html Karabekiroglu K, Doğangün B, Hergüner S, von Salis T and Rothenberger A (2006) Child and adolescent psychiatry training in Europe: Differences and challenges in harmonization. European Child and Adolescent Psychiatry 15: 467–475 Osrin D, Azad K, Fernandez A, Manandhar DS, Mwansambo CW, Tripathy P and Costello AM (2009) Ethical
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challenges in cluster randomized controlled trials: Experiences from public health interventions in Africa and Asia. Bulletin of the World Health Organization 87: 772–779 Patel V and Kim Y (2007) Contribution of low- and middle-income countries to research published in leading general psychiatry journals, 2002–2004. British Journal of Psychiatry 190: 77–78 Remschmidt H, Nurcombe B, Belfer ML, Sartorius N and Okasha A (2007) The Mental Health of Children and Adolescents: An Area of Global Neglect. Chichester: John Wiley & Sons Rescorla L, Achenbach TM, Ivanova MY, Dumenci L, Almqvist F, Bilenberg N, Bird H, Broberg A, Dobrean A, Döpfner M, Erol N, Forns M, Hannesdottir H, Kanbayashi Y, Lambert MC, Leung P, Minaei A, Mulatu MS, Novik TS, Oh KJ, Roussos A, Sawyer M, Simsek Z, Steinhausen HC, Weintraub S, Metzke CW, Wolanczyk T, Zilber N, Zukauskiene R and Verhulst F (2007) Epidemiological comparisons of problems and positive qualities reported by adolescents in 24 countries. Journal of Consulting and Clinical Psychology 75: 351–358 Saxena S, Paraje G, Sharan P, Karam G and Sadana R (2006) The 10/90 divide in mental health research: Trends over a 10 year period. British Journal of Psychiatry 188: 81–82 Schuklek U (2000) Protecting the vulnerable: Testing times for clinical research ethics. Social Science and Medicine 51: 969–977 Sharan P, Gallo C, Gureje O, Lamberte E, Mari JJ, Mazzotti G, Patel V, Swartz L, Olifson S, Levav I, de Francisco A, Saxena S and WHO Global Forum for Health Research Mental Health Research Mapping Project Group (2009) Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean. British Journal of Psychiatry 195: 354–363 Sridhar D and Batniji R (2008) Misfinancing global health: A case for transparency in disbursements and decision making. Lancet 372: 1185–1191 Sridhar D, Khagram S and Pang T (2009) Are existing governance structures equipped to deal with today’s global health challenges towards systematic coherence in scaling up? Global Health Governance 2: 1–25 Tyrer P (2005) Combating editorial racism in psychiatric publications. British Journal of Psychiatry 186: 1–3 WHO (World Health Organization) and Joint Editors (2004) Galvanizing mental health research in low- and middle-income countries: Role of scientific journals. http://www.who.int/mental_health/evidence/en/final_joint_ statement.pdf [accessed 5 October 2009] World Medical Association (2001) Declaration of Helsinki: Ethical principles for medical research involving human subjects. Bulletin of the World Health Organization 79: 373–374
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Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Challenges in international collaboration in child and adolescent psychiatry a
Hesham M Hamoda & Myron L Belfer
a
a
Children's Hospital Global Partnerships in Psychiatry, Children's Hospital Boston and Harvard, Medical School , 300 Longwood Ave, Boston, MA, 02115, USA Published online: 15 Nov 2010.
To cite this article: Hesham M Hamoda & Myron L Belfer (2010) Challenges in international collaboration in child and adolescent psychiatry, Journal of Child & Adolescent Mental Health, 22:2, 83-89, DOI: 10.2989/17280583.2010.528577 To link to this article: http://dx.doi.org/10.2989/17280583.2010.528577
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
Downloaded by [Bangor University] at 14:23 28 December 2014
& Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Journal of Child and Adolescent Mental Health 2010, 22(2): 83–89 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/17280583.2010.528577
Commentary Challenges in international collaboration in child and adolescent psychiatry
Downloaded by [Bangor University] at 14:23 28 December 2014
Hesham M Hamoda* and Myron L Belfer Children’s Hospital Global Partnerships in Psychiatry, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA * Corresponding author, e-mail: [email protected] International collaboration in child and adolescent psychiatry has historically been weak and fragmented. The field has also lagged in developing remedies for improving collaboration. This article identifies barriers to successful collaboration and examines problems in the areas of finance, professional development, knowledge dissemination, professional organisations, public policy and the political environment, priority setting, nomenclature, as well as ethical challenges. The article then identifies some promising initiatives and proposes solutions to improve international collaboration in child and adolescent mental health.
Introduction While there are many obstacles to collaboration in child mental health in developed countries, the obstacles to productive collaboration across low and middle income (LAMI) countries and between LAMI and developed countries are daunting. In an era where the dissemination of evidencebased practices is essential, overcoming barriers for collaboration is of paramount importance. Controversial aspects of international collaboration need to be identified. Collaboration needs to be guided by the immediate and long-term benefits for the populations studied, and be rigorous enough to be valuable as research. The global health scene, including that of global child mental health is characterised by fragmentation, lack of coordination and even confusion. Many initiatives in global health have been criticised as being narrowly focused on specific diseases rather than systems-wide strengthening (vertical rather than horizontal), tend to be ‘top-down’ in nature and are largely driven by donor agendas rather than the country’s own needs and priorities (Sridhar, Khagram and Pang 2009). Many of the initiatives lack mechanisms of accountability, transparency and evaluation (Sridhar and Batniji 2008). A review of the research literature reveals that the rigor of cross-cultural research is often less than would be expected (Saxena et al. 2006) in part, because the research has been conducted with an apparent lack of awareness of contemporary findings in others settings and inappropriate use of randomised controlled trials (RCT). It is now clear that RCTs have major shortcomings when trying to implement findings in real life settings where contextual factors and co-morbidities impinge on programme design and implementation (Friedman and O’Reilly1997). Child mental health research lags in identifying ways in which international collaboration can be improved. The issues are particularly crucial for child psychiatry given the shortage of professionals
Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
84
Hamoda and Belfer
with research training and the global demand for implementation of evidence-based programmes for children affected by disasters, war and social upheaval. This article identifies barriers to successful collaboration by examining problematic areas and proposes solutions to improving international collaboration in child mental health. We note that considerable variability exists both within and between developing and developed nations, nevertheless, we tried to identify some general themes that may impede collaborative efforts.
Downloaded by [Bangor University] at 14:23 28 December 2014
Obstacles to collaboration The obstacles to collaboration internationally are understandable, but can be overcome with careful planning, development of trusting relationships and attention to seemingly mundane impediments, such as, language, financial transactions, International Review Board approvals, among others. Particular to child mental health is the paucity of well trained child mental health professionals in developing countries who can interact with each other and with governments. This limitation is key for the dissemination of the unique knowledge associated with child mental health and undermines the development of programmes and policies. Language differences impede understanding. Even within regions presumed to be using the same or similar language, differences in understanding can be profound. For instance, in the Eastern Mediterranean region it is often easier to use Classical Arabic or even English or French as the common communication language than to attempt the reconciliation of meaning using different Arabic dialects. Attempts to identify major international child mental health collaborative efforts that meaningfully involved colleagues from developing countries yield few results, and fewer still in the peer reviewed literature. Models for successful collaboration are difficult to find. An exception has been the standardization of screening instruments and measures of psychopathology where many studies have been conducted. However, there are methodological challenges associated with applying Western instruments in populations that differ dramatically than those for which they were developed (Hollifield et al. 2002). These international studies more commonly investigate reliability rather than validity across cultural groups and are weak on cultural relevance (Betancourt et al. 2009). The World Health Organization (WHO) can provide access to resources, but usually is not a source of major financial support. The WHO can ease many political barriers that would otherwise be insurmountable. Some have suggested that ‘the only organization with the political credibility to compel cooperative thinking is the WHO’ (Garrett 2007: 14–18). WHO-supported model programmes can also provide a common frame of reference for programme or research collaboration. It can and should provide the incentive and support for international collaboration on a broader scale. The WHO ‘is uniquely positioned to provide this leadership by virtue of its role in setting evidence based norms on technical and policy matters, highlighting best practices that improve health globally, and monitoring and coordinating action to address current and emerging global health threats’ (Institute of Medicine 2009: 28). For instance, the WHO Suicide Prevention Program, SUPRE-MISS, involved countries from all WHO regions in an elaborate research protocol. In recent years the WHO Assessment Instrument for Mental Health Systems (AIMS) project, the WHO Atlas initiatives and the current WHO Mental Health Gap Action Programme (mhGAP) programme has fostered meaningful data gathering and provided a basis for collaboration while not in themselves representing crosscountry collaboration. Obstacles to collaboration not only exist at the international level, but also nationally. Within countries, almost universally, there is competition in the academic sector. Rivalries and distrust can impede collaboration. Finding the means for research and programmatic governance can ease the distrust. Care needs to be taken to ensure constant communication among the involved parties. Within country economic disparities lead to widely differing levels of service delivery. Unfortunately, the economic disparity also leads professionals to migrate to centers where financial support and community can provide for a better life.
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Problematic areas for collaboration Finance Funding is problematic everywhere. Specific concerns arise when funding comes with restrictions that limit the development of programmes or research that is culturally relevant and respects the rights of the child and family. The mobilisation of financial resources for complex international multi-site trials for clinical interventions has been very difficult. The same is not true for research instrument validation studies that have strong support from the originator/ sponsor (Rescorla et al. 2007). Governments appear reluctant to ‘subsidise’ other countries by funding research projects abroad. Non-governmental funders of international collaborations require accountability that is often difficult to achieve. Pharmaceutical companies have been supportive of international collaboration, but often with a narrower focus on the efficacy and effectiveness of a particular medication for a particular disorder. Major foundations often request a North-South partnership which imposes constraints on potential collaborative efforts among more than two or three collaborators. The absence of identifiable child and adolescent mental health budgets in LAMI countries and the episodic nature of NGO funding undermine stable collaboration. The transfer of money between countries is often very difficult and the taxes imposed (direct and indirect) may erode the value of any grant. While international meetings provide an important venue for sharing information, research results, and networking, funding for such meetings is still highly dependent on pharmaceutical companies’ support. Professional development Besides adequate funding, collaborative efforts in child and adolescent mental health need trained human resources. Collaboration in the realm of professional development and developing human capital offer a different set of challenges. Child psychiatrists in the European Union seek a uniform set of training standards across Europe through the European Union of Medical Specialists (Karibekiroglu et al. 2006). While it is possible to articulate a clear set of standards, it requires considerable political agility to get standards adopted, and overcome resistance in recognising child psychiatry as an independent discipline. Additionally opportunities for clinical training for young child and adolescent psychiatrists from developing countries in Western institutions are limited, with many familiar barriers: culture, language, finances, licensure, and accreditation. Amongst the few applicants able to overcome these obstacles and receive training in Western countries, even fewer return to their countries of origin, which adds to the ‘brain drain’ phenomenon. For those who do return, there are questions about the relevance of their training when they practice in environments where basic mental health services and medications are lacking. The problems with collaborative efforts do not rest solely with the less developed countries. It is difficult to secure time away from clinical work or research to pursue overseas collaborative work in a sustained way, and there are few financial incentives to address this. Interestingly, psychology graduate students and post-doctoral fellows have more support to pursue research abroad and thus we see in this generation the majority of pediatric mental health research being carried out by non-child psychiatrists. Knowledge dissemination Researchers from both developed and developing countries face common challenges that require them to acquire skills in research methodology, grant writing, fundraising and basic statistical knowledge. There is however a set of challenges that are unique to researchers from developing countries including writing in English and choosing appropriate journals for their submissions (Ehrlich, Jefferson-Lensky and Plener 2007). Earlier the issue of language was mentioned as a barrier to collaboration. A second important language issue is the use of the language of scientific writing. The training of collaborators in this domain may not be equivalent. There is a learning
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gradient for some to be able to understand the complexity of protocols, the meaning of particular interventions, and how to communicate their research findings. A study by Patel and Kim reviewed original research contributions from LAMI countries published over a three-year period in the six highest-impact general psychiatry journals. The study found that only 3.7% of published research emerges from these less affluent countries, which account for over 80% of the global population (Patel and Kim 2007). The authors proposed several explanations for their findings including the overall low proportion of submissions from LAMI countries, the possibility that authors from these countries might be choosing local journals for their research, and the low research output and research capacity in these countries. In part, this lack of capacity is associated with a lack of psychiatrists. In addition the authors suggested other potential explanations on why articles from LAMI countries are more likely to be rejected; the quality of the research and editorial and reviewers attitudes towards articles from these countries, a view shared by others (Tyrer 2005). Collaboration among professional organisations Professional associations that are international in scope have existed for generations. In the past, rivalries around areas of clinical concern or the composition of groups led to a decrease in the potential for mutual advocacy and advancement of the field. Now, the leadership of these professional organisations has recognised the overwhelming need to act in concert for effective advocacy and thus many have joined in forming a Global Consortium to advance education and advocacy. The Consortium includes the International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP), World Association for Infant Mental Health, the International Association for Adolescent Psychiatry and Psychology, the World Federation for Mental Health and the International Association for Child Mental Health in Schools. This marks a significant departure from the fragmentation of the past, though there are still tensions in the rivalries between child-focused clinical disciplines and adherents to particular clinical philosophies. Public policy and the political environment Research and programme policy development at the level of national governments is lagging worldwide. This hampers collaboration because there is no reference for how to proceed, what are the limits of liability, and what the sanctions are for research or novel clinical interventions. With the development of more interventions in developing countries this is an area of great interest and discussion. International policy is even less evident. The United Nation Convention on the Rights of the Child provides some guidance at the extremes but does not provide specific guidance for research or clinical intervention (the USA and Somalia are the only two countries that have not ratified this convention). In addition, what may be acceptable in one country or region may not be acceptable in another. For instance, the place of children in society may differ and this leads to a lessening or heightening of concern to provide care or to expose children to interventions. The failure to mobilise political will is key to the observed lack of development of public policy for child mental health. As for any political process mobilising resources, forming alliances and political activism will be essential to put child mental health on the political agenda at both the national and global levels. Differing agendas There may be legitimate differences in the research interests and priorities between developing and developed nations. For example, researchers from developing countries may be in urgent need to conduct epidemiological and culturally specific research, whereas researchers from Western nations typically have resources that allow for other types of studies including sophisticated, biologically-based research. A recent study examining mental health research priorities in LAMI countries identified epidemiology, health systems and social science as the highest priorities in mental health research (Sharan et al. 2009). Once again, a major guiding factor in collaboration needs to be a clear delineation of expectations, an understanding of how resources can be shared to achieve these goals, and an open forum for discussing the possible barriers along the way.
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Nomenclature A major contemporary challenge for international research, as it relates to epidemiology and clinical intervention, is the need to reconcile the common classifications of mental illness. ICD-10 and DSM-IV, even with differing criteria, are now widely recognised as being inadequate for the diagnosis of childhood mental disorders, especially because they lack adequate inclusion of knowledge about developmental processes and cultural variations. This leads to problems in research generalisation as well as designing interventions, and will likely require a classification system that would be more dimensional and would meaningfully integrate cultural variables. Ethical challenges The risk of exploitation, the imposition of Western values, and the distortion of clinical findings could and have permeated the partnerships between Western researchers and those in developing nations (Osrin et al. 2009, Schuklek 2000, World Medical Association 2001). Not all centers in developing countries have institutional review boards and ethical standards for research may vary. Western scientific research standards and scientific journals require that such safeguards exist. Ethical issues also arise when research on children and adolescents is conducted in developing countries where there are no or few child psychiatrists and in situations where studied populations will not benefit directly from the research findings. Ways forward Despite the numerous challenges there are precedents for successful international collaboration. The World Psychiatric Association (WPA), the IACAPAP and WHO developed a Global Child and Adolescent Mental Health Program during the WPA presidency of Ahmed Okasha (Remschmidt et al. 2007). With sufficient financial resources, international leadership sensitive to the particular challenges facing transnational collaboration, and the involvement of knowledgeable professionals, two global collaborative research projects were initiated, including a study of the impact of school drop-out in Russia, Brazil, and Egypt, and the development of an awareness manual addressing stigma related to children and adolescents with mental disorders, which was based on data gathered from nine developed and developing countries (Hoven et al. 2008). Earls and colleagues demonstrated a multilevel collaborative effort with the goal of enhancing personal agency and community efficacy (Earls, Raviola and Carlson 2008). Among psychiatric journals there is an increasing awareness of the importance of supporting publication of research from LAMI countries. For example, Peter Tyrer, the editor of the British Journal of Psychiatry notes that ‘this is more than a mere question of equity; if we do not acknowledge the contribution of the 90% adequately [referring to developing countries that constitute 90% of the world], we may lose essential elements of knowledge in our attempts to develop a complete picture of the etiology, course and management of mental disorders’. Tyrer recommended increasing research capacity and manuscript development skills as a remedy to this problem (Tyrer 2005: 1–3). He also noted that a small number of journals, including the British Journal of Psychiatry, promote a minor form of positive discrimination, asking referees to be more generous in assessing articles from the 90% under-represented countries. In 2004, The WHO and the editors of scientific journals issued a consensus statement expressing concern about the wide gap in research evidence, and emphasised the role of scientific journals in promoting research from LAMI countries (WHO and Joint Editors 2004). This is an important step, yet the effectiveness of these initiatives is still to be evaluated. Clinicians should seek international collaborations that are not limited to research. Establishing clinical collaborative networks through mentorship of clinicians from developing nations, teaching courses, giving presentations, and consulting on difficult cases are all activities individual clinicians could engage in. Considering longitudinal involvement with one country could allow for a better understanding of the unique challenges in that country and provide for a more meaningful collaboration.
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Finally, innovative programmes for clinicians from developing nations for short term clinical placements in Western institutions could also provide unique opportunities particularly if they focus on teaching skills that are applicable in developing countries. An example is the international child mental health training programme at Children’s Hospital of Boston’s Department of Psychiatry that is co-sponsored with the Department of Social Medicine at the Harvard Medical School. The programme provides one to three month observer participation in clinical teaching at Children’s Hospital and participation in didactics at the Department of Global Health and Social Medicine at the Harvard Medical School. The programme focuses on skills that could be used in developing countries and is not intended for clinicians who are planning to practice in the USA.
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Conclusion With the shift in the emphasis in public health from infectious diseases to non-communicable diseases, as well as the increase in the acceptance of seeking mental health treatment in many communities, the opportunities for our field are tremendous. The current generation of child psychiatrists and other child mental health professionals have embarked on new collaborations less burdened by past rivalries or ideological constraints. The momentum is present within the groups to sustain clinical, research and training efforts and to provide mentorship. This encouraging development bodes well for future collaborations that will overcome barriers to communication, build natural alliances and seek resources to expand efforts on behalf of children and adolescents across the globe. Ackowledgement — During the time the manuscript was revised, Dr Hamoda was supported by a DupontWarren Fellowship Award from the Harvard Medical School Department of Psychiatry. The authors report no conflicts of interest to disclose relevant to the content of this article. The authors alone are responsible for the content and writing of this article. It has been presented in part at the International Association of Child and Adolescent Psychiatry and Allied Professions Congress in Beijing, China, June 2010.
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