International Review of Psychiatry, August 2010; 22(4): 355362

Child psychiatry and mental health in Latin America

RODRIGO CHAMORRO OSCHILEWSKY1, CRISTOBAL MARTINEZ GOMEZ2, 3 & EDGARD BELFORT
1 2

International Institute of Cognitive Development, Central University of Chile, Chile, University of Moron, Argentina, Department of Psychiatry, Faculty of Medicine, University of Havana, Cuba, and 3Department of Psychiatry, Central University of Venezuela, Caracas, Venezuela

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Abstract The review of epidemiological studies of psychiatric disorders in children and teenagers in Latin America, is validated and updated in this article. The present article incorporates variants that are contributed from the neurosciences, which allow us to see difficulties as opportunities, across such mechanisms as the plasticity neuronal, trying to change paradigms, frequently pessimistic in this type of review, and we call for the active participation of all the scientific societies of our countries in the development of public policies, based on prevention, for the vulnerability of the rights of our children and teenagers suggesting a multidisciplinary boarding in mental health.

Introduction It is not uncommon that when making reports on the mental health situation in Latin America, factors such as poverty, multi-racial or ethnic terms, the number of psychiatrists in our countries, the number of psychiatric beds, the scholarship, etc. are variables to be included in any report as factors explaining the situation to work with our patients, and there is little or no description of the role that scientific societies impact in the development of mental health public policy in our governments. From the field of neuroscience there have been reports, in parallel, with significant changes that must be considered for inclusion in our diagnostic criteria, therapeutic and preventive, as this is where public policy should settle (Chamorro, 2007; Kendler, 1995). Analysis of epidemiological information It is estimated that about 7 to 22% of children and adolescents have a disabling mental illness and that suicidialidity is the third cause of death in teenagers. Other studies have shown a prevalence of 21% in children and adolescents between 9 and 17 years (MECA; Kandel, 1999). In a study in a pediatric hospital in Colombia it was established that the most prevalent diseases in the population of children and adolescents were impaired learning, attention deficit disorder with hyperactivity, depression and suicide associated

disorders anxiety, pervasive developmental disorders, disorders of eating behaviour (DEB), the disorders associated with psychoactive substance use, conduct disorders and psychotic disorders (Rohde, Celia, & Berganza, 2004). Although this study was conducted in a pediatric hospital, comparing studies should be considered that the prevalence of these conditions change as the population studied. Similarly, the records obtained from the populations attending specialized services have specific characteristics (UNICEF, 1999). Patients treated at a pediatric hospital of high complexity have some special features, as a local reference site, regional and/or national level. In this study, the patients treated had an average age of 10 years, and two thirds were boys. Between 90% and 100% of patients have comorbidity, and consulting service for the first time almost 45% do not return to controls. He found that the number has tripled interconsultation with respect to data of 2000 in the same hospital. The studies presented here do not differ significantly from the results presented in 2003 in the MECA study (Shaffer et al., 1996). Latin American countries have great contrast in mental health public policies in children and adolescents, in research and training of mental health teams. The differences range from the most high and complex interdisciplinary programmes in child mental health programmes based on comprehensive primary care models such as Chile and Cuba, strong

Correspondence: Dr Rodrigo Chamorro Oschilewsky, Department of Neuropsychology, University of Moron, Argentina. Tel: 56-2-2417684. E-mail: rchamorro@manquehue.net ISSN 09540261 print/ISSN 13691627 online 2010 Institute of Psychiatry DOI: 10.3109/09540261.2010.503692

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R. Chamorro Oschilewsky et al. compared with children who still live with their lowincome families (Rohde et al., 2004). Another major risk of harm in adolescent mental health in some countries of Latin America has to do with social and political conflicts. It is estimated that 6000 to 14,000 children are involved in armed conflicts in Latin America, and over 10,000 children are in the army in Paraguay (Belfort, 2002). In the last decade, economic improvements in some Latin America countries have made possible the allocation of additional resources which are important for programmes devoted to promoting child development and improve the lives of children in general, who are assigned some of these resources, specifically mental health. These programmes are designed to address problems identified as priorities by the countries; however, with few exceptions, these programmes have not been systematically evaluated or made part of a sociological monitoring study (Belfer & Rohde, 2005). As we know, the creation of public health programmes should be monitored regularly for flexible strategies, as they change the dynamics that become the ambioma [environmental factors]. This point is crucial and makes these programmes sustainable and efficient over time (Chamorro, 2007). Many programmes are designed to improve access to services and to reduce historical exclusion from appropriate services. Exclusion in health is an important indicator in the case of children with possible mental health problems, school dropout rates can also be regarded as an indicator of risk. Drop-out rates are high in some Latin American countries due to the need for children to work for income generation in their families or because they must stay home to care for younger siblings. We must remember that dropping out of school can play a significant role in mental health status compared with those who remain in school, so this situation poses a major problem in the Latin American countries, such that intervention programmes in mental health prevention, environmental variations must include both the family and the school (Belfer & Rohde, 2005). Epidemiological studies of mental health specific to Latin American countries are essential for developing programmes that meet the needs of affected populations in children and adolescents. Most Latin American nations lack data using nationally representative samples that provide the necessary guidance for public policy development in this area (Duarte et al., 2003). The few studies found have been conducted with population samples drawn from relatively small and homogeneous local areas within countries, and/or studies to address specific mental health problems such as attention deficit hyperactivity disorder (ADHD) (Chamorro, 2008;

intervention programmes generated from government institutions, as in Brazil and Costa Rica, or led to research groups associated with generating training programmes in Argentina, Brazil and Chile. (Rohde et al., 2004), however, this contrasts, for example, with the reality in Haiti. Before the earthquake, it was estimated that up to 20% of those under 15 years old are vulnerable, living in poverty, undernourished, with limited access to education or in foster care, domestic work, or on the street. In the 514 age groups, infectious and parasitic diseases accounted for 24% of total deaths. External causes represented 10% of all causes of death. Infant mortality increased from 73.8 per 1000 live births in 1996 to 80.3 in 2000. This increase is associated with increased poverty, deficiencies in the health system and the impact of the AIDS epidemic. Today, after the earthquake, the situation the situation is critical, and till now, not quantifiable. In recent years, with regard to the framework established by the signing of many countries that ascribe to the Declaration of the Rights of the Child to the United Nations (UN), public policy in many Latin American countries has been lining up on the responsibility forbreaking the inequality, based on rights. However, several Latin American countries have some of the highest risk children with mental health and vulnerability, related for example to use of inhalants, an endemic situation in parts of Brazil and Mexico, with abandoned children or the streets at high risk to engage in criminal behaviour or quickly enter the world of addiction, as a survival strategy, and are mostly neglected populations in Brazil and many other parts of Latin America. In the possibility of requiring health care and public programmes or private, Latin America shows some of the most dramatic discrepancies in income distribution in the world. Some studies have suggested that approximately 10% of the population earns 90% of total revenue (Jolly & Cornia, 1984). Different economic problems in Latin American nations over the past two decades have resulted in a substantial reduction in the proportion of people in the middle class and a huge decline in investment in social and health programmes (UNICEF, 1999), marked particularly by the latest global economic crisis. In the psychosocial domain, many children in Latin American countries face risk factors of enormous proportions. Poverty forces many children to live in the streets and predisposes them to participate very early in their lives in drug use, crime, violence and unprotected sex. This has serious health consequences, including mental health (Inciardi & Surratt, 1998). These homeless children demonstrate significant deficits in development related to social reciprocity, moral precepts, and self-esteem

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Child psychiatry and mental health Rohde et al., 1999). Thus, any conclusion about the overall prevalence of mental health disorders among children and youths in Latin American countries should be considered as an estimate. Most epidemiological investigations carried out in Latin American countries have used instruments which are similar to research conducted in developed countries, and without adequate cross-cultural validation. Although some child psychiatric disorders, particularly those who have a clear biological basis may have a similar clinical presentation in both developing and developed countries (Rohde et al., 1999), studies show the role played in the evolution of the environment of different mental disorders associated with the variation with which these occur depending on the different cultural contexts (Fleitlich-Bilyk & Goodman, 2004). A study in Brazil evaluated the prevalence of psychiatric disorders in school children and adolescents aged 7 to 14 years in the state of Sao Paulo (Fleitlich-Bilyk & Goodman, 2004). The diagnoses were based on the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (APA) (DSM-IV) in evaluating the development, welfare and a structured interview informant assessment. The latter instrument was extensively tested for validity across cultures. The sampling was random schools (stratified into private, public, rural and urban public). A sample of 1251 subjects was evaluated. The overall weighted prevalence of psychiatric disorders was 12.7%. Disruptive behaviour disorders (oppositional defiant disorder or conduct disorder) were the most frequent conditions (7%), followed by anxiety disorders (5.2%). Lowest prevalence was found for hyperkinetic disorder (1.8%), and depressive disorder (1%). The 12.7% overall weighted prevalence of mental disorders was significantly higher than the prevalence of 9.7% given in Britain in a study with similar diagnostic procedures (Belfer & Rohde, 2005). The results of this study in Brazil and other epidemiological studies of mental health among youths tend to suggest that, when using similar methodologies, developing countries and developed countries have similar results in terms of estimated prevalence, age trends, gender differences, and the pattern of comorbidity (Duarte et al., 2003). However, we must consider that very few studies have been performed with adequate methodologies to investigate the impact of risk factors and protective prevalence rates of mental disorders of children in Latin American countries, as epigenetic variables do not appear ambyomic [environmental factors] considered in the studies, despite what we initially supposed. Further studies about Latin American countries were included in the Atlas Project of the World

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Health Organization (WHO, 2005), which show the countrys resources for the study of the mental health among adolescent boys. The survey from a questionnaire documented the presence or absence of childrens mental health policies at national or local level in many countries of Latin America. Some importance derived from this study is the confirmation that there is a large gap between the written rules and their implementation. This seems to be associated with the lack of political will to develop and maintain public policy, human and financial resources to implement the policy and failure to follow policy once these have been implemented. The Atlas project and other sources have also documented the importance of non-governmental organizations (NGOs) in the health care systems in Latin American countries (WHO, 2005). Bolivia Mental health is a part of primary health care system in Bolivia. Actual treatment of severe mental disorders is not available at the primary level. Less than 25% of the population is covered by this type of service. Mental health care consists of primary health care provided by psychiatrists. A referral system is in place. Regular training for primary care professionals is not carried out in the field of mental health. There are community care facilities for patients with mental disorders. The community care system for the mentally ill includes outpatient clinics, preventive and promotion interventions, home interventions, as well as residential facilities and vocational training; however, these services are available for less than 25% of the population. Primary health care doctors and nurses are responsible for taking care of patients with mental disorders in the community (WHO, 2005). A notable example of this is also observed in Costa Rica. The Paniamor Foundation aims to protect the human rights of children. This foundation focuses on preventing human rights violations via the exchange of information, education, training, work in communities and public campaigns. The results of their efforts have shown: 1) increased awareness and prevention of child abuse; 2) the promotion and participation in the development of new legislation to improve the mental health of children and protect their human rights; 3) reintegration of high-risk adolescents into schools and/or job training; and 4) creating the largest database of child welfare in Central America. Other NGOs are participating in mental health programmes for children and adolescents of Latin America in many other ways. For example, associations of relatives of patients with mental disorders in some Latin American countries have been working to

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R. Chamorro Oschilewsky et al. policies, they have designed a plan with a strategy based on the community. This could have to be an effective way to help children who normally have no access to health care, education, proper nutrition, or a safe place to live. In particular, this type of research will assess the impact on childrens health in general and on mental health. This research also describes the importance that actions related to health varies with the childs age, gender, socioeconomic status, and location, as well as with what is intended to alter health indicators associated with the objective of the program. Ecuador A national mental health programme is present in Ecuador. The programme was formulated in 1980 and it was revised in 1999. It was also implemented by 10% less than expected by regional and national authorities, probably because there was no specific budget for its implementation. Its main components are strategy of services reform, integration of mental health services within primary health care, and development of specialized services. There is also a mental health reporting system in the country. Information is recorded utilizing ICD-10 (Sartorius, 1995). The mental health components reported are morbidity, admissions and discharges. Depression, suicide, psychosis, drug abuse and dependence, epilepsy, mental retardation, violence and child abuse are the conditions covered. The country has a data collection system and an epidemiological study on mental health. The Departamento Nacional de Estatsticas (National Department of Statistics) is in charge of the data collection system for mental disorders. It is also stated that the main psychiatric problems are alcohol abuse and dependence (7.4%), affective disorders, particularly depression (approximately 16%), psychosocial problems such as domestic violence and child abuse (WHO, 2005), (Kohn, Levav, Caldas, 2005). Jamaica The work to be developed in this country is based on the observation that there is significant impairment of optimal development in the years of infancy, and its impact on school failure in elementary and secondary school years; this happens in many countries, but is particularly common in developing countries. There is relatively little information available about the factors that contribute to developmental disorders in children from developing countries. Jamaicas research and intervention programmes are expected to include early childhood education, community work and seminars for parents, child health

promote better treatment of children with mental illness (e.g. ADHD, Autism syndrome, etc.). The study of the WHO Atlas Project has documented that Latin American countries vary in terms of guidance, both theoretical and practical, doctors and the types of services provided. The Atlas and other sources reported a virtual absence of access to medications in some regions of Latin American countries. Historical and cultural roots are often the basis of differences in the clinical services available. Nations vary in the amount used by people who have no mental health training to provide care to children with mental disorders. Some countries have many psychologists, learning specialists, and other similar professionals who can participate in the development of a continuum of care, while other nations have virtually none of these specialists. Most services and training in Latin America are concentrated in large cities, whether in public or private universities. The existing initiatives depend most of the time on personal and institutional efforts, rather than public policies. Moreover, important changes have taken place, both in the training and practice of mental health professionals which have evolved from orthodox psychoanalysis to systemic therapies, biological psychiatry, and cognitive neurobiological model; thus affecting a paradigm shift in diagnostic and therapeutic approaches. Currently the Pan American Health Organization (PAHO) has assumed an important role in identifying and supporting research that is relevant to public policy concerns. PAHO and WHO are working closely with the Medical Schools of Harvard University and Columbia University to support the development of research projects resulting from a model of assessment of key issues of some countries of Latin America. Representative projects from Brazil, Chile, Colombia, Costa Rica, and Jamaica have already been identified. Some of the research objectives in this regard are as follows: 1) identify principles that should guide the development of child mental health policy in the Latin American countries and 2) initiate a debate on specific principles, objectives and strategies related to the formulation and implementation of mental health policy of children from Latin American countries (WHO, 2005). Brazil Enacted in 1990, the Child and Adolescent Rights Act goes beyond a declaration of child rights, and actually mandates the implementation of these rights. The law states that all Brazilian municipalities must have a child rights council and a council of guardianship of the child. Directed to a population at high risk from negative results observed in previous

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Child psychiatry and mental health programmes and development screening, and education in health centres, modulated by a culturally relevant professional to record child development, in-service training for the care and training of primary school teachers directed to support them in providing appropriate educational materials on child development in nursery and primary schools (WHO, 2005). Costa Rica A model of depression treatment to protect children and strengthen families exists in Costa Rica based on the premise that when parents are depressed, the disease affects not only them but also all areas of family functioning. Any treatment approach for depressed parents should take into account known risk as well as factors for depression, and should have a prevention component. A family-based strategy seems to be particularly suitable for carrying out these tasks. This project in Costa Rica will test the validity of a model of depression treatment that has already been used elsewhere. This model is intended to prevent depression from parents and, thus, avoid consequences for their children. This project will also train local health workers in using this model. In turn, these professionals are responsible for training other local health professionals to propagate and extend the coverage of the intervention of depressed parents and their families (WHO, 2005). Cuba Mental health is a part of primary health care system in Cuba. Actual treatment of severe mental disorders is available at the primary care level. Cuba has developed a system that prioritized primary care and preventive care. More than 95% of the population is covered by this type of service. Mental health care is provided by primary health care physicians and psychiatrists. A system of referral is also in place. Regular training of primary care professionals is carried out in the field of mental health. In the last two years, about 120 personnel were provided training. The country has currently one doctor for about 200 persons; that is, the worlds highest doctorpatient ratio. This makes the integration of mental health in primary care a little easier. Each year between 4% and 5% of primary care personnel from a wide range of disciplines are trained. There are available community care facilities for patients with mental disorders. The community care system for the mentally ill provides this coverage. Cuba has a particular programme based on the approach of risk, community participation and intersectoral coordination. It puts a special emphasis on the mental health of the family as a determinant factor of the mental

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health of the child. It is centred on the community, at the level of primary care, and across the family doctor, via our advising and continued education. The applied (hardworking) and the investigation (research) included in this programme has the focus to give a response to all the problems that are detected. It is based on three essential aspects: The diagnosis of the health situation, the analysis of this situation, and the plan of action for the solution of the problems. The approach of these three aspects is clinical, epidemiological and social (WHO, 2005). Child and adolescent mental health programme This programme is based on risk factors, community participation, and the inter-sector coordination. Special emphasis is placed on the familys mental health as the determining factor for the childs mental health. It is centred on the community, at the level of primary care through the family doctor, and with ongoing advice and continuing education. The research efforts used in this programme are incorporated in the programme with the objective of finding answers to all the problems detected in this programme. The programme consists of three essential aspects: the health related diagnosis, the analysis of the health status, and the plan of action for troubleshooting of the problems encountered. The focuses of these three aspects are: clinical, epidemiological and social. The philosophy behind our work is based on how we introduce ourselves in the community, and also becoming an integral part of the community; thus, deepening our knowledge of the community as well as the use of the community resources for its own benefit. Once we have diagnosed the childs or adolescents mental health status, we proceed to analyse the health status, to identify and prioritize the problems encountered, as well as taking into account the needs felt and not felt by the residents of the community. We then proceed with the interdisciplinary teamwork to identify which are the health problems. This approach should be done with the joint participation of the team and the community, and using methods such as discussion groups. The criteria used for prioritizing our approaches are as follows: social transcendence, population opinion and impact, magnitude of the damage, as well as rates comparison and indicators. Also, assessment of the real possibility of modifying the problem. Costtime-resources: to achieve certain effects are also taken into consideration. The plan of action is defined as follows: jointed organized, coherent and integrated with activities and services carried out simultaneously or in succession, and with the necessary resources in order to

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R. Chamorro Oschilewsky et al. study. The children had a lower proportion of repeaters that the whole group. As compared in this study the magnitude of problems between repeaters and non-repeaters ensures that the former have more problems. On the other hand the difficulties reported by teachers at both behavioural and cognitive levels were higher than those reported by parents, which forces us to rethink educational plans adjustments, according to the population that is being educated, not maintain rigid educational schemes, but modulated by applying different teaching sociocultural environments (De La Barra, Toledo, & Rodriguez, 2005).

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` achieve the desired objectives vis-a-vis the health problems of the defined population (community). To operate this programme, we count with a workforce of 204 child and adolescent psychiatry specialists distributed throughout the 14 provinces of the country, with 11 million population, as well as an organized primary healthcare system. The strives for a strong community focus are based on: 1) We have established work objectives to strengthen the protective factors, strong emphasis in controlling the risk factors, ensure early diagnosis, and provide a timely treatment and rehabilitation of childhood mental disorders; 2) We have as the main purpose of the Programa Nacional de Atencion Materno Infantil, to ensure a strong mental health status for children and adolescents; we also attempt to consolidate and improve the levels of health and mental health of the mother and the child; 3) The health, education, social security, legislative, non-governmental organizations, and international agencies are all ready to coordinate their efforts in order to ensure a high quality of life for our children and adolescents.

Colombia In recent years, Colombia developed a pilot programme in Medellin, called the Coexistence Programme, which has used public education to raise awareness, mediating with various groups. This current initiative has not achieved the expected success; however, community leaders and scholars are convinced that an intervention of this nature can prevent violence. The aim is based on two elements: 1) a programme that can intervene in the growth and development of children in early stages, and 2) an initiative to create modular and healthy schools, where the motivation for learning is the fortress. This intervention is applied based on the social ecology concept developed by Earls and colleagues (Muzzio, Kentros, & Kandel, 2009), along with the concept of life course health development used for many years by the World Health Organization (WHO, 2005).

Chile Based on the evidence of the development of health services in Chile, research has shown that an integrated health intervention that transforms the experience of a childs life improves outcomes of child development, pointing to the need for health care systems that are designed to improve health in development. The purpose of this research in a middle-income area of Chile is to improve knowledge about child development, and contribute to policy formulation on child development through scientific evidence on health care. Today, in public community health centres not only do we identify the risk factors of development, and vulnerability of family and social system, but also augmentation strategies are timely implemented, trained educators and joint strategies are developed from health and education is given from early childhood to children, based on the policy framework of citizenship rights (WHO, 2005). A mental health study in two cohorts of school children in an area of Santiago de Chile, allowed determining of the early behavioural and cognitive predictors, where we found gender differences in various behavioural problems as teachers: higher scores for men in disobedience/aggression, cognitive deficits, hyperactivity and concentration problems, both in first and in sixth grade. The reviews of gender differences in various aspects of development show that they depend largely on social stereotypes. Parents reported no gender differences in the prevalence of behavioural problems in this

Current challenges and future perspectives Advances in the neurosciences should be considered. Recently, research in neurosciences has been very productive, for instance, neuroplasticity phenomena described in hippocampal areas and the risk of inhibiting the development of new neuronal populations in this important area, such as when the collapse of dendritic pruning produces serotonin or the recent description of the activation of brain circuits or description of a group of neurons called mirror neurons, which have recently been associated with phenomena not only cognitive but also emotional, such as empathy (Kandel, 2009; Muzzio et al., 2009; Rizzolatti & Fabbri-Destro, 2010). Advances in human genome, proteomics and psychopharmacology allow us to understand how genes dialogue with the synapse, altering the brain and its functions in a sort of plastic dance, regulated environmentally. It is important to remember that most mental illnesses are polygenic, and the

Child psychiatry and mental health influences are many. The genetic interaction of dispositional and environmental inhibition or activation is responsible for the clinical expression of these disorders (Kandel, 2009). On the other hand it is already a fact that epigenetic changes modulated by our changing lifestyle from psychotherapy and the use of psychotropic drugs, are more easily moulded than the change that we make from the genome. For example, the review of recent research on the genomic and epigenetic studies focusing on chromosome 17, a gene promotes the formation of the serotonin transporter. There are individual variations acting as a sort of regulator, whose role is to delay the expression of the gene, generating polymorphisms in the nucleotide sequence of the trigger button, which results in constraints of exophenotype to be processed in a particular way, generating high to low activation of neural systems that process the threat, the environmental risk and/ or fear, which undoubtedly will affect physical responses, as well as cognitive and emotional changes that are determined by this variation (Gelernter, Pakstis, & Kidd, 1995). It is from this precept, that psychopathology on children and adolescents in Latin America must be investigated, not only from the prevalence, incidence, co morbidity and treatment perspectives, but from the phenomenological and clinical evolution as well. Another variable is related to the percentage of disorders expressed as psycho-neuro-development disturbances, both in the field of behaviour, impulse control and emotional self-regulation or cognitive disorders, including pervasive developmental disorders. Neurodevelopment involves the transformation of human beings in time and this is accomplished by two mechanisms: first maturation, which is the actualization of the potential transmitted by heredity, and the other is learning, defined as the permanent change in behaviour as a result of experience or activity of the individual with the environment. Maturation is a gradual process and is genetically determined, with periods of greatest vulnerability connected to structural processes (Chamorro, 2007). It is therefore important for the mental health teams involved with these children to understand that the processes are evolutionary, and the classic look of the medical model can be inefficient, and often too quick to diagnose disorders, but not the understanding of the relationship between these biological processes specific to the child and adolescent, family and school environment. Thus, epidemiological studies of infant-juvenile psychiatry have evolved and require developmental epidemiological outlook (De La Barra, 2009). Conclusion

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We cannot consider variables such as inequality within Latin American countries, modulated by the ethnic composition, macroeconomic developments, schooling, access to more sophisticated technological means, the number and levels of training for those mental health infant juvenile variants that hamper epidemiological studies; however, there has been a modest influence on the participation of our scientific societies in public mental health policy; this variable has been modified in some countries, both from initiatives of their own societies and/or their governments, as the outstanding participation of APAL in promoting conventions and suggestions in this area: working with governments, NGOs and multinational agencies (WHO) to generate appropriate strategies for the care of children and adolescents in mental health services; implementing training and research in Latin American countries, based on experiences from other regions of the world that have faced or are now facing similar challenges. The role of scientific societies such as the World Psychiatric Organization (WPA) and the Latin American Psychiatric Association (APAL) will be essential, but must also involve these scientific groups actively involved in child and youth mental health activities in the region in order to conduct comprehensive and multidisciplinary projects. Finally, the difficulties which face children and adolescents in Latin America can be transformed into opportunities, based on the current knowledge of genomics and neuroscience; we must enable the development of appropriate resilience in our children and teenagers and transform their deficits in opportunities. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References
Belfer, M., & Rohde, L. (2005). Child and adolescent mental health in Latin America and the Caribbean: Problems, progress, and policy research. Revista Panamericanca de Salud Publica, 18(45), 359365. Belfort, E. (2002). Reflexiones sobre la salud mental infantile en el context de Latinoamerica. Psiquiatria y Salud Integral [Thinking about the mental health infantile in the context of Latin America. Psychiatry and Integral Health], 2, 3842. Chamorro, R. (2007). Inteligencia, diversidad cognitive-emocio nal. Terremotos y sonadores. TDAH Journal [Intelligence, cognitive-emotional diversity. Earthquakes and dreamers. Argentine TDAH Journal], 12(5), 912. Chamorro, R. (2008). Revista Electronic de la Asociacion Peruana de Deficit de Atencion [Electronic Magazine of the Peruvian ADHD Association]. Available at http:// www.deficitdeatencionperu.org/m-dicos-/trastorno-por-d-ficitatencional-una-disfunci-n-ejecutiva.-aportes-de-la-neurocienciacognitiva.html (accessed July 2008). Boletin Electronico

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R. Chamorro Oschilewsky et al.

disorders in Latin America and the Carib: Priority matter for the public health. Revista Panamericana de Salud Publica, 18(4/5), 229240. Muzzio, I.A., Kentros, C., & Kandel, E. (2009). What is remembered? Role of attention on the encoding and retrieval of hippocampal representations. Journal of Physiology, 15(587), 28372854. Rizzolatti, G., & Fabbri-Destro, M. (2010). Mirror neurons: From discovery to autism. Experimental Brain Research, 200(34), 223237. Rohde, L.A., Biederman, J., Busnello, E.A., Zimmerman, H., Schmitz, M., Martin, S., & Tramontina, S. (1999). ADHD in a school sample of Brazilian adolescents: a study of prevalence, comobid conditions and impairments. Journal of the American Academy of Child and Adolescent Psychiatry, 38(6), 716722. Rohde, L.A., Celia, S., & Berganza, C. (2004). Systems of care in South America. In H. Remschmidt, M. Belfer & I. Gooyer (Eds.), Facilitating pathways, care, treatment and prevention in child and adolescent mental health (pp. 4251). Heidelberg, Germany: Spring Verlag. Sartorius, N. (1995). Understanding the ICD-10 Classification of Mental and Behavioural Disorders, Pocket Reference. Science Press Ltd, London. Shaffer, D., Fischer, P., Dulcan, M.K., Davies, M., Piacentini, J., Schwab-Stone, M.E., et al. (1996). The NIMH Diagnostic Interview Schedule for Children version 2.3(DISC-2.3): Description, acceptability, prevalence rates and performance in the MECA study. Journal of the American Academy of Children and Adolescent Psychiatry, 35, 865877. UNICEF (1999). The progress of nations. New York: United Nations Childrens Fund. WHO (2005). Atlas: Child and adolescent mental health resources: Global concern: Implications for the future. Geneva, Switzerland: World Health Organization.

Int Rev Psychiatry Downloaded from informahealthcare.com by HINARI on 06/01/11 For personal use only.

No 23, July 29, 2009: Dr R. Chamorro (Chile) www. deficitdeatencionperu/boletines.htm. De La Barra, M. (2009). Children and adolescents mental health: Why is investigation necessary? Revista Chilena de NeuroPsiquiatria, 47(3), 169250. De La Barra, F., Toledo, V., & Rodriguez, J. (2005). Prediction of behavioral problems in Chilean school children. Child Psychiatry and Human Development, 35(3), 227243. Duarte, C., Hoven, C., Berganza, C., Bordin, I., Bird, H., & Miranda, C. (2003). Child mental health in Latin America: Present and future epidemiological research. International Journal of Psychiatry Medicine, 33(3), 203222. Fleitlich-Bilyk, B., & Goodman, R. (2004). Prevalence of child and adolescent psychiatric disorders in southeast Brazil. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 727734. Gelernter, J., Pakstis, A.J., & Kidd, K.K. (1995). Linkage mapping of serotonin transporter protein gene SLC6A4 on chromosome 17. Human Genetics, 95, 677680. Jolly, R., & Cornia, G.A. (1984). The impact of world recession on children. New York: Pergamon. Inciardi, J.A., & Surratt, H.L. (1998). Children in the streets of Brazil: Drug use, crime, violence and HIV risks. Substance Use Misuse, 33(7), 14611480. Kandel, D.B. (1999). Psychiatric comorbidity among adolescents with substance use disorders: Findings from the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(6), 693699. Kandel, E.R. (2009). The biology of memory: A forty-year perspective. Journal of Neurosciences, 29(41), 1274812756. Kendler, K.S. (1995). Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Archives of General Psychiatry, 52(11), 895999. Kohn, R., Levav, L., Caldas de Almeida, J.M., Vicente, B., Andrade, L., Caraveo-Anduaga, J.J., et al. (2005). The mental