ESCAP board meet in Belgrade

ESCAP board members were warmly welcomed by a team of child and adolescent psychiatrists and psychologists, and deans of the faculty, who all have a similar vision for Serbia; to improve the standards, educational level and the number of child and adolescent psychiatrists within Serbia, thus to meet the demanding mental health needs of Serbian children.
This was an opportunity for the members of DEAPS and representatives from the Department of Psychiatry to summarise the situation of child and adolescent psychiatry in their country to ESCAP board members and address questions to the board on how to overcome the challenges they face.
Curriculum in child and adolescent psychiatry in Serbia
Child and adolescent psychiatry was recognised as a clinical discipline in 1993 in Serbia. Since then, the curriculum has been adapted to accommodate this speciality, and currently, there are two elected courses on the undergraduate program; Autism Spectrum Disorder and Child Abuse and Neglect Prevention and Protection, these are comprised of lectures and practical sessions. In postgraduate studies, the specialisation in child and adolescent psychiatry started as a separate discipline in 1994. The speciality lasts four years and takes place at clinics, institutes, hospitals, departments for psychiatry and child psychiatry, paediatric clinics, and departments for child neurology. Having this curriculum in Serbia is already a huge achievement for those involved. However, it doesn’t flow without its problems.
There is still no separate department for child psychiatry, and there is only one professor of child psychiatry at the University of Belgrade in the Department of Psychiatry. It is important to mention that there are only two professors of child psychiatry in the whole of Serbia. This is insufficient for the needs of the country. In addition, academic progression is restricted for the trained child and adolescent psychiatrist. The department of psychiatry employs adult psychiatrists, who only receive two months of child training in their academic program, again insufficient to treat the high numbers of children and adolescents. Any efforts to enhance the curriculum must be processed by the university council, and becoming a member of the UEMS has been problematic.
Designing and developing the ideal curriculum can be achieved, however with so few professors in the country, who will teach these specialisations? ESCAP board members suggested inviting visiting teaching professors from other countries. It was also stressed that to promote the mental health of young people in Serbia, they need to open the medical issues to the society and community. It is important to raise awareness and develop preventative strategies, by doing so it changes the whole life cycle of an individual. By involving the community and raising awareness, it will put pressure at the political level. Mental health in young people is a public health issue, as pointed out by ESCAP policy division head Dr Füsun Çuhadaroglu Çetin, that the psychiatric needs worldwide have increased, there needs to be a certain amount of hours/classes in the medical training programs to keep up with these current needs. The WHO has a comprehensive mental health action plan 2013–2020, providing a framework for strengthening capacities in countries to address the mental health needs of children and adolescents. Serbian health ministries and university councils need to work together to adopt and action this framework.
The position of child psychiatrists in the Serbian healthcare system
DEAPS members and Faculty of Medicine Dean and vice Dean

DEAPS members and Faculty of Medicine Dean and vice Dean

Currently, there is one psychiatrist to every 25,896 for children and adolescents aged 0-18 year in Serbia. The needs are high and the resources insufficient. The existing number of health organisations and services that deal with the mental health of children and adolescents is inadequate, and partially, dysfunctional. There is a lack of experts educated to work with children and adolescents with mental health problems and a scarcity of beds in the only two institutions in the capital. This has knock-on consequences, and DEAPS are doing what they can to rectify these major obstacles.
The strategy is to look at the needs of the children and the needs of the carer, to strengthen what is already in place and follow the practices established in other countries. Ultimately, the aim is to protect the mental health of children and adolescents and provide care from birth to adulthood. This strategy requires intersectoral collaboration.
Thus, the following will be necessary:
  1. Education: Introducing basic knowledge of child and adolescent psychiatry into the educational programs for nurses (several hours), and medical students (more exercises and classes); and increase the number of specialists by having a clear employment plan in regional centres, health centres and paediatric clinics within university centres (establishment of somatopsychic, psychosomatic and somatoform regimens and prevention of psychopathological comorbid conditions through liaison teams). Conducting evaluation tests in the educational framework of paediatricians. Strengthening post-graduate studies and involving doctoral students in research related to developmental disturbances and disorders.
  2. Prevention: Enabling more comprehensive preventive actions, most importantly early diagnostics and overall assistance to children, adolescents and their families on the level of primary health care.
  3. Continual education: Additional education for personnel in community health centres (gynaecologists, general practitioners, paediatricians and associates) in fields relating to mental health issues in children and adolescents.
  4. Services: Strengthening personnel, organisations, facilities, and aiding existing specialised services for mental health problems in children and adolescents in secondary and tertiary institutions by increasing the number of specialists in child and adolescent psychiatry, as well as providing a better distribution of personnel.
  5. Standards: Introducing norms for working in the field of child and adolescent psychiatry.
  6. Additional units: Forming small units for mental health of children and adolescents within future centres and connecting them with existing development counselling centres and youth counselling centres.  
  7. Emergency services: Develop services within multiple institutions on a 24 h basis to have the capacity and resources to receive children and adolescents in urgent cases.
  8. Diagnosis: Extending the list RF30 with a greater number of indicative fields (diagnostic categories) for mental disorders in childhood and enabling better availability for psychopharmacotherapy for children and adolescents with mental health problems.
  9. Specialised treatment: Enhancing intersectoral and interdisciplinary approaches with the purpose of enabling adequate treatment of children and adolescents with behavioural disorders and chronic aggressive behaviour (further strengthening the connection with the social protection system).
The geographical diversity of the ESCAP board was an advantage here, as many members provided experience and strategies developed in their home countries. Health ministries and child and adolescent psychologists in Turkey recognised that psychologists required specialised training in child and adolescent mental health. Thus, courses were integrated into the psychology training and certificates were given upon completion of the specialised program. In the past in Germany, paediatricians were giving children drugs for certain mental health disorders due to the lack of specialised child and adolescent psychiatrists, however, they were unaware of the required doses and that these were affecting the neurodevelopment of children and having consequential mental health issues later in life. Along with Germany’s strategy of training more psychiatrists in child and adolescent psychiatry, the drug issue was rectified, and now only child and adolescent psychiatrists can prescribe specialised drugs to children affected by certain mental health disorders, complying with policies established in many other countries.  
Developmental paediatrics
A few years back, UNICEF introduced various educational programs for paediatricians in the field of mental health. Until then, the mental health of children and adolescents was relatively undermined. Only with this initiative did the paediatric specialists receive the possibility of gaining knowledge in their surroundings. Developmental paediatrics was introduced as an optional subject to undergraduate studies. However, the subject still excludes problems of socioemotional and cognitive development.  
The aim in Serbia is to provide an overall protection of children's mental health through balanced geographical availability. The idea is to link child psychiatrists with adult psychiatrist and to also be present in paediatric clinics in bigger centres so that liaison teams can be formed (child psychiatrist, psychologist, educational technician) and eventually in bigger community health centres.
Worryingly, child psychiatrists are absent in inpatient hospitals in Serbia. As beds are filled, more strain is put on the doctors to try to treat these special cases and on the psychologists, who are not only trying to address the patient’s psychological problems and needs but deal with the pressures put on family and siblings. Recently, psychiatrists and paediatricians in Serbia have established a more opened dialogue and should be congratulated by doing so. It is a step in the right direction and by having all these disciplines collaborating and focusing on the child’s needs will ensure that barriers will be removed, and communication and cooperation will lead to treatment and, hopefully, a cure.
What advice would you give to DEAPS on their strategies to move forward in child and adolescent psychiatry?
How has your country overcome similar obstacles?
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