Introduction
Child and adolescent mental disorders are common and linked to pre-mature death and serious dysfunction in adult life [
1]. About half of all mental disorders start by the age of 14 years and three-quarters before the age of 25 [
1,
2]. Worldwide prevalence rates of child and adolescent mental disorders are around 10–20%, with similar types of disorders, such as anxiety disorder, behaviour disorder and mood disorders seen across cultures [
2]. Nepal is a low-income country with a total population of approximately 20 million, of whom 40% (12 million) are younger than 18 years of age [
3,
4]. The Ministry of Health and Population of Nepal estimates that about 15–20% of this population (2–3 million) may suffer from some form of mental disorder [
4,
5].
Mental health is shaped to a great extent by social, economic and environmental factors [
6]. Exposure to a range of environmental adversities increases the risk of disorders in children through the biological embedding of environmental risk. Poverty, a lower social position in society, war and exposure to violence in neighbourhoods have all been shown to have negative influences on the development of child psychopathology [
7]. Unfortunately, many more children and adolescents in Nepal are exposed to such factors, and often more so than their peers in high income countries. For example, almost half (41.6%) of all children in Nepal are living under multidimensional poverty as measured across health, education and living standards [
8]. Children from poorer backgrounds are likely to have a greater exposure to child labour, exploitation and human trafficking, domestic violence and sexual abuse [
4,
9‐
12]. Moreover, the changing family structure due to divorce, separation from joint family to nuclear family, parental neglect and parental substance abuse also put children at a higher risk of psychosocial and mental health problems [
12].
Natural disasters like earthquakes, floods, and landslides are common in Nepal [
13,
14]. The massive earthquake of 2015 directly affected 1.7 million children in Nepal [
13]. Such disasters lead to displacements, disappearances, injuries and death affecting families, children and their mental well-being. Despite this, child and adolescent mental health problems and disorders have been unacknowledged for many years in Nepal.
Only recently, has there been greater importance given to identifying and treating mental disorders in children [
4,
5]; however, the magnitude of child and adolescent mental problems in Nepal is still not clear. There are many reasons for this, including the absence of a child and adolescent mental health policy, poor child and adolescent mental health services (there is only one outpatient child and adolescent mental health clinic in the whole country and no inpatient facilities), as well as an acute shortage of child and adolescent psychiatrists and allied professionals (only one child and adolescent psychiatrist in the whole country). Furthermore, no specialized postgraduate training in child and adolescent psychiatry is available in Nepal and limited research is performed [
4,
15‐
18]. The Government of Nepal has allocated less than 1% of its total health budget for mental health; child and adolescent mental health services receive a negligible portion of this amount [
18,
19].
This paper aimed to provide an overview of child and adolescent mental health problems in Nepal.
Methodology
This study used a scoping review approach and employed the following inclusion criteria: any type of study reporting on mental health disorders in children and adolescents, conducted in Nepal, published in English or Nepali. Two databases (PubMed and Medline were searched from their inception to August 2018, using terms ‘mental disorder’, ‘child and adolescent’ and ‘Nepal’). Titles and abstracts were examined using the inclusion criteria, after which full articles were retrieved.
According to Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Review Guideline (PRISMA-ScR), the critical appraisal of the included studies is an optional item [
20]. However, we performed the critical appraisal taking into account that it will help to consider the methodological quality of the included studies while interpreting the findings from those studies. For critical appraisal, the methodological quality assessment tool of the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Cross-Sectional Studies, [
21] and the Guidelines for evaluating prevalence studies [
22] were used. Given that, this was a comprehensive scoping review, and not a systematic review, one reviewer performed the quality assessment, and another co-author later confirmed it. There were no articles excluded based on the quality criteria.
Discussion
This paper has provided an overview of child and adolescent mental health problems in Nepal. Only ten eligible studies were identified. Among these, seven were population studies, while three studies assessed clinical samples.
There is a small but growing evidence base on child and adolescent mental health problems and disorders in Nepal [
23‐
32]. Unfortunately, all studies were relatively small. The most common mental health problems assessed among children and adolescents of Nepal as found in this review are PTSS symptoms, followed by emotional and behavioural problems. Likewise, children and adolescents exposed to the aftermath of the recent earthquake, those involved in war, as well as homeless and school-going children are the most well-studied groups so far.
The rate of PTSS symptoms among earthquake-affected children and adolescents of the Kathmandu district reported in this review varied greatly (10.7% to 51%). These wide variations could be due to differences in methodology. The study that reported a higher rate of PTSS was conducted among both children and adolescents [
23], while the study that reported a lower prevalence assessed only adolescents [
27]. Likewise, there was difference in the study settings in these two studies, as one of the studies was a community-based study that adopted multistage cluster sampling and including 800 earthquake-affected children and adolescents [
23], while the other was a school-based study conducted in three schools and including 440 adolescents [
27]. However, the prevalence rate of PTSS symptoms (51%) is similar to the prevalence rate of 47.7% among children 3 months after a major earthquake in Turkey [
33] and to the prevalence rate of 44% among children 1 year after a major earthquake in China [
34].
The prevalence of emotional and behavioural problems among sheltered homeless children was 28.57% [
25], which is in the range of the rates of 24% to 40% in a meta-analysis on mental illness in homeless children [
35]. Consistent with previous studies, this study showed that internalising problems are more common in girls than boys, and the opposite for externalising problems [
35,
36].
Heys et al. estimated that the prevalence of autism was 0.3% [
26], which is lower compared to the estimated prevalence of 1.89% in South Korea [
37]. This difference might be due to differences in methodology. The study in Nepal used the AQ-10 screening tool in 4098 children and adolescents while the study in South Korea used the Autism Spectrum Screening Questionnaire in 55,266 children and adolescents.
The prevalence of psychosocial problems among adolescents in a school-based sample ranged from 12.09 to 17.03% [
28,
29]. This prevalence is similar to the rate of 14.3% found in Sub-Saharan Africa school age children, as shown by one the meta-analysis [
38].
The prevalence of ADHD in one of the hospital-based studies in Nepal was 10% [
30], which is similar to the rate of 11% among children in a hospital-based study in Uganda [
39]. However, this is less than the prevalence of 20.3% among children in a hospital-based study in India [
40].
The studies included in this review were not free from limitations. Only two out of ten studies were rated as of good quality. Most of the included studies were cross-sectional and descriptive in nature, conducted with small samples collected through convenient sampling techniques and different settings; therefore, the findings of the study cannot be generalised to the entire population of children and adolescents of Nepal. In addition, most of the screening tools used for these studies were not validated for use in a Nepalese context, which might be also be considered as a threat to both the internal and external validity of the study findings. Very few population studies have studied mental health problems and disorder among children and adolescents in Nepal, so this scoping review included the available clinical studies conducted to assess common mental disorders among children and adolescents in clinical samples. Hence, the findings from clinical studies included in this scoping review should be interpreted cautiously as they do not provide an estimate of actual disease prevalence in the general population.
Strength and limitation of the study
According to our knowledge, this is the first scoping review that has provided an overview child and adolescent mental health problems in Nepal. This study has also provided the quality assessment of the included studies. However, the search was limited to only two databases for convenience and therefore some relevant studies might not have been identified. However, given the dearth amount of literature on this important topic, these findings remain useful.
Implications of the study
The findings of this study have implications for policy initiatives and service delivery. Given the context of Nepal where there is a lack of child and adolescent mental health plan and policy, the findings of the prevalence of child and adolescent mental health problem in this study suggest that there is a need of child and adolescent mental health policy and plan in the country. Policy makers and service delivery should explore and implement evidence-based approach for promoting and protecting child and adolescent mental health. They should create a competitive mental health workforce that can address the existing child and adolescent mental health problems.
Conclusion
1.
The existing literature demonstrates that mental health problems and disorder are common among the children and adolescents of Nepal. However, methodological variations, poor quality and constraints across those studies make it difficult to reach firm conclusions on the true prevalence of mental health disorders in children and adolescents in Nepal and suggest a huge research gap in the field of child and adolescent mental health in the country.
2.
There have been no national level prevalence studies on child and adolescent mental health problems and disorders in Nepal.
3.
More research that is robust is required to assess the prevalence of child and adolescent mental health problems and disorder.
4.
Future research should use total population or representative sample and valid screening and diagnostic tool and contribute toward providing the true prevalence of different child and adolescents mental health problems and disorder in the country.
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