CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOLOGY IN BOSNIA AND HERZEGOVINA – STATE AND PERSPECTIVES SARAJEVO, 2017. POSEBNA IZDANJA KNJIGA CLXXIII Odjeljenje medicinskih nauka Knjiga 50 AKADEMIJA NAUKA I UMJETNOSTI BOSNE I HERCEGOVINE ACADEMY OF SCIENCES AND ARTS OF BOSNIA AND HERZEGOVINA АКАДЕМИJА НАУКА И УМJЕТНОСТИ БОСНЕ И ХЕРЦЕГОВИНЕ ANU BiH АНУ БиХ Zbornik radova Urednik Slobodan Loga Naučni simpozij DJEČIJA I ADOLESCENTNA PSIHIJATRIJA I PSIHOLOGIJA U BOSNI I HERCEGOVINI – STANJE I PERSPEKTIVE Sarajevo, 5. aprila/travnja 2014. godine Department of Medical Sciences Volume 50 SPECIAL EDITIONS VOLUME CLXXIII AKADEMIJA NAUKA I UMJETNOSTI BOSNE I HERCEGOVINE ACADEMY OF SCIENCES AND ARTS OF BOSNIA AND HERZEGOVINA АКАДЕМИJА НАУКА И УМJЕТНОСТИ БОСНЕ И ХЕРЦЕГОВИНЕ ANU BiH АНУ БиХ Proceedings SARAJEVO 2017 Editor Slobodan Loga Scientific Symposium CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOLOGY IN BOSNIA AND HERZEGOVINA – STATE AND PERSPECTIVES Sarajevo, April 5, 2014 DOI: 10.5644/PI2017.173.00 CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOLOGY IN BOSNIA AND HERZEGOVINA – STATE AND PERSPECTIVES Publisher Academy of Sciences and Arts of Bosnia and Herzegovina For Publisher Academician Miloš Trifković Editor Academician Slobodan Loga Reviewers Gordana Milavić, Vera Daneš-Brozek, Slobodan Loga, Milica Pejović, Zoran Juretić, Suad Kapetanović, Esad Boškailo, Klaus Schmeck, Nirvana Pištoljević, Amer Smajkić, Asim Haračić, Mihela Erjavec, Vesna Srkalović Translators Adnan Arnautlija Sanja Malić Vladimir Miletić Jelena Vojčić Language editors for Bosnian/Croatian/Serbian language Jasminka Hadžić Amra Mekić Language editors for English language Sanja Malić Vladimir Miletić Roman Skalić Anida Šehanović DTP Narcis Pozderac, TDP Sarajevo Circulation 150 CEEOL Sarajevo 2017 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 5 CONTENTS Sabina Kučukalić, Nermina Čurčić-Hadžagić, Alma Mehmedbašić-Bravo, Abdulah Kučukalić DJEČIJA I ADOLESCENTNA PSIHIJATRIJA KAO SAMOSTALNA USTANOVA ILI U SKLOPU ODRASLE PSIHIJATRIJE CHILD AND ADOLESCENT PSYCHIATRY AS AN INDEPENDENT INSTITUTION OR AS A PART OF ADULT PSYCHIATRY ......................................... 7 Slobodan Loga, Nirvana Pištoljević, Emira Švraka, Vera Daneš, Bojan Šošić CURRENT STATE AND PERSPECTIVES OF CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOLOGY IN BOSNIA AND HERZEGOVINA TRENUTNO STANJE I PERSPEKTIVE DJEČIJE I ADOLESCENTNE PSIHIJATRIJE I PSIHOLOGIJE U BOSNI I HERCEGOVINI ................................. 16 Klaus Schmeck, Susanne Schlüter-Müller DEVELOPMENT OF CHILD AND ADOLESCENT PSYCHIATRIC SERVICES IN CENTRAL EUROPE: HEALTH POLICY IMPLICATIONS OF THE SITUATION IN SWITZERLAND, GERMANY AND THE NETHERLANDS RAZVOJ PSIHIJATRIJSKIH USLUGA ZA DJECU I ADOLESCENTE U CENTRALNOJ EVROPI: IMPLIKACIJE SITUACIJE U ŠVICARSKOJ, NJEMAČKOJ I HOLANDIJI NA ZDRAVSTVENE POLITIKE ................................. 31 Gordana Milavić CHILD AND ADOLESCENT MENTAL HEALTH SERVICES CLINICAL ACADEMIC GROUP AT THE MAUDSLEY HOSPITAL IN LONDON KLINIČKA AKADEMSKA GRUPA ODJELA MENTALNOG ZDRAVLJA KOD DJECE I ADOLESCENATA PRI BOLNICI MAUDSLEY U LONDONU ........ 41 Milica Pejović Milovančević, Vladimir Miletić MENTAL HEALTH CARE IN SERBIA – CHILD AND ADOLESCENT MENTAL HEALTH (CAMH) MENTALNA ZDRAVSTVENA ZAŠTITA U SRBIJI - MENTALNO ZDRAVLJE DJECE I ADOLESCENATA (CAMH) ............................................................................ 50 Mirjana Remetić, Mirzada Kurbašić RANI SKRINING NA AUTIZAM U PRIMARNOJ PEDIJATRIJSKOJ SLUŽBI EARLY SCREENING FOR AUTISM IN PRIMARY CARE SETTING ........................ 63 Mira Spremo, Tatjana Marković-Basara, Nada Vaselić, Slobodan Spremo NEGATIVE EMOTIONAL STATES AND QUALITY OF LIFE IN PARENTS OF CHILDREN WITH AUTSTIC SPECTRUM DISORDER NEGATIVNA EMOCIONALNA STANJA I KVALITET ŽIVOTA RODITELJA DJECE SA POREMEĆAJEM AUTISTIČNOG SPEKTRA .......................................... 72 Nada Vaselić, Gordana Bukara-Radujković, Mira Spremo DEPRESSION OF CHILDREN WITH DIABETES DEPRESIVNOST DJECE OBOLJELE OD DIJABETESA ......................................... 82 Tea Vučina RAZLIKOVANJE PREDIKTORA RAZLIČITIH STADIJA KORIŠTENJA MARIHUANE DISTINCTION OF PREDICTORS FOR DIFFERENT CANNABIS USE STAGES .. 94 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 7 DOI: 10.5644/PI2017.173.01 Pregledni rad DJEČIJA I ADOLESCENTNA PSIHIJATRIJA KAO SAMOSTALNA USTANOVA ILI U SKLOPU ODRASLE PSIHIJATRIJE Sabina Kučukalić, Nermina Čurčić-Hadžagić, Alma Mehmedbašić-Bravo, Abdulah Kučukalić UKC Sarajevo, Psihijatrijska klinika, Odjel za dječiju i adolescentnu psihijatriju, Sarajevo, Bosna i Hercegovina Autorica za korespondenciju: Sabina Kučukalić sabina.sahbegovic@gmail.com Lektorica za bosanski jezik: Amra Mekić Lektor za engleski jezik: Roman Skalić Primljen: 2014, prihvaćen: 2016, objavljen: 2017. Apstrakt Cilj: Prikazati sadašnji model funkcioniranja i analizirati buduće perspektive Odjela za dječiju i adolescentnu Psihijatriju pri Psihijatrijskoj klinici, Univerzitetskog kliničkog centra Sarajevo. Pozadina: Odjel za dječiju i adolescentnu psihijatriju Psihijatrijske klinike postoji preko 50 go- dina. Funkcioniše kao jedini odjel za dječiju i adolescentnu psihijatriju u Federaciji Bosne i Hercegovine. Ciljna grupa odjela su djeca i adolescenti u dobi od 3 do 18 godina koji imaju odre- đene psihičke poteškoće. Pacijentima se usluge pružaju kroz ambulantu, dnevnu bolnicu i zatvo- reno odjeljenje. Osim toga, postoji i savjetovalište za djecu i roditelje. Zbog ekonomskih razlo- ga i profesionalnih razmjena smatramo da je bolje da Odjel funkcioniše u okviru Psihijatrijske klinike za odrasle. Glavni nedostatak ovog modela funkcionisanja se ogleda u kasnom početku tretmana zbog straha od stigmatizacije. Metode: Uporediti model funkcionisanja Odjela za dje- čiju i adolescentnu psihijatriju u Sarajevu sa drugim klinikama za liječenje djece i adolescenata sa psihičkim smetnjama. Diskusija: U većini zemalja liječenje djece i adolescenata sa psihičkim poremećajima se organizira u okviru samostalnih klinika. Poredeći rad Odjela u sklopu UKC Sarajevo sa radom Zavod u sklopu KBC Zagreb vidimo da se radi o dva veoma slična modela organizacije, ali da je osnovna razlika u dostupnosti adekvatno obrazovanog kadra bez obzira što se tretira otprilike jednak broj djece i adolescenata sa različitim smetnjama. Još veću razliku uočavamo ako poredimo rad Odjela za dječiju i adolescentnu psihijatriju Sarajevo sa radom sa- mostalnih klinika, na primjer, Psihijatrijska bolnica za djecu i mladež Zagreb ima 78 zaposlenih različitih edukativnih profila. Naš Odjel ima samo 10 zaposlenih, iako liječimo približno isti broj pacijenata. Zaključak: Cilj nam je u budućnosti uspostaviti samostalnu kliniku za djecu i adolescente. Za ovaj koncept potrebna su finansijska sredstva, multidisciplinarni profesionalni tim, oprema i prostorije čija raspoloživost zavisi od interesovanja vlasti. Ključne riječi: dječija i adolescentna psihijatrija, perspektive, organizacioni modeli. 8 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 7-15. Prema podacima iz Sjedinjenih Američkih Država, 20% djece i adolescenata (oko 15 mili- ona) u razdoblju od 9 do 17 godina imaju primjetan psihijatrijski poremećaj (1). Prevalenca pojedinih teških poremećaja kao što su bipolarni poremećaj, velika depresivna epizoda (8%, 12-17 g.), ADHD (6,8%) poremećaji iz autističnog spektra (1/ 100, 88, 68 djece u toku 2012., 2013., 2014.,g.) se značajno povećala u proteklih nekoliko godina (1, 2). Prema podacima Svjetske zdravstvene organizacije 45% svjetske populacije je živjelo u državi gdje je bio manje od 1 psihijatar na 100.000 stanovnika (3). Podaci iz Bosne i Hercegovine govore da je u 2014. godini na 100.000 stanovnika u BiH bilo 4 psihijatra. U susjednoj Hrvatskoj je te iste godine na isti broj stanovnika bilo 10,25 psihijatara (3). Ovaj podatak nas čini državom koja je u Evropi na samom dnu po broju psihijatara. Nije naveden podatak koji se posebno tiče dječijih i adolescentnih psihijatara, ali sudeći po ovim podacima taj broj bi bio poražavajući. Sa druge strane, samo 20% djece sa emocionalnim poremećajima dobije ade- kvatan tretman od strane stručnjaka iz polja mentalnog zdravlja, a još manji broj dobija adekvatnu evaluaciju i tretman (4). U Sjedinjenim Američkim Državama, prema podacima iz 2014. godine, ima oko 8000 specijalista dječije i adolescentne psihijatrije na populaciju od oko 15 miliona djece i mladih (4). Tako da se danas čak govori o „kolapsu sistema dječije i adolescentne psihijatrije“, jer postoji ogromna razlika između pojedinih država jer u nekim nema niti jednog psihijatra iz ove uže specijalnosti. Iako se smatra da će broj psihijatara do 2020. godine porasti za 30%, to će opet biti nedovoljno, jer je prema broju djece i adolescenata potrebno oko 12.000 psihijatara kako bi se adekvatno zadovoljile njihove potrebe (4, 5). Organizacija Odjela za dječiju i adolescentnu psihijatriju Univerzitetskog kliničkog centra (UKC) Sarajevo Odjel za dječiju i adolescentnu psihijatriju Psihijatrijske klinike UKC Sarajevo po- stoji već 50 godina. Jedini je odjel za dječiju i adolescentnu psihijatriju u Federaciji Bosne i Hercegovine. Na Odjelu se liječe djeca u dobi od 3 do 18 godina. Odjel ima klinički odsjek, dnevnu bolnicu, ambulantu i savjetovalište za dijete i porodicu. 1. Klinički odjel (10 pacijenata), 2. Dnevna bolnica (10 pacijenata), 3. Ambulanta (1500 pacijenata godišnje), 4. Savjetovalište za dijete i porodicu (700 pacijenata godišnje), 5. Intenzivna njega (pri odrasloj Psihijatriji). Terapijske aktivnosti na Odjelu za dječiju i adolescentnu psihijatriju UKC Sarajevo � Grupna terapija adolescenata, � Kognitivno-bihejvioralna terapija (KBT), � Psihodinamska orijentirana psihoterapija, Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 9 Sabina Kučukalić et al.: Organizacija dječije i adolescentne psihijatrije � Psihoedukacija roditelja kroz individualni i grupni pristup, � Grupa roditelja – jedanput sedmično, � Okupaciona terapija: terapija igrom, likovna terapija i muzikoterapija, � Psihofarmakološka terapija, � Saradnja sa školama, vrtićima i centrima za socijalni rad. Dnevna bolnica pri Odjelu za dječiju i adolescentnu psihijatriju UKC Sarajevo U dnevnu bolnicu se primaju pacijenti kojima ambulantni tretman nije dovoljan, a ne postoji indikacija za stacionarno liječenje. Vrši se detaljna dijagnostika (medicinska, psihološka i pedagoška). Također, vrši se multimodalno planiranje terapije od strane specijalista dječije i adolescentne psihijatrije. Primjenjuje se strukturirani pedagoški program, koji djeci i adolescentima pruža orijentaciju za praktičnu primjenu u sva- kodnevnom životu. Postoje jasna pravila na Odjelu uz pozitivno potkrepljivanje i nagrađivanje. Uključeno je savjetovanje roditelja i trening roditelja. Redovno se odr- žavaju kontakti i savjetovanja sa vrtićima i školama koje djeca pohađaju. Najčešće dijagnoze kod prijema djece su: hiperkinetski poremećaji, poremećaji socijalnog ponašanja, razvojni poremećaji, emocionalni poremećaji, opsesivno-kompulzivni poremećaj, razvojni poremećaji školskih sposobnosti, tik poremećaji, enureza, en- kompreza, poremećaji ishrane, somatoformni i disocijativni poremećaji, psihotični i postpsihotični poremećaji. Medicinski kadar trenutno uposlen na Odjelu čine: � Dva neuropsihijatra, � Jedan psiholog, � Pet medicinskih sestara na stacionaru, � Jedna medicinska sestra kao okupacioni terapeut, � Jedna glavna sestra Odjela. Prikaz funkcioniranja: Klinika za psihološku medicinu Rebro – Zavod za dječiju i adolescentnu psihijatriju i psihoterapiju Zavod se sastoji od Poliklinike sa ambulantnom djelatnošću (specijalističke ambu- lante), dnevne bolnice sa 20 mjesta, kao i stacionarnog psihijatrijsko-psihoterapij- skog odjela sa 10 postelja. Zavod je nosilac referentnog centra za dječiju i adolescen- tnu psihijatriju pri Ministarstvu zdravlja RH, kao centra izvrsnosti u ovom području, odnosno jedna od vrhunskih institucija u Hrvatskoj u području dječije i adolescentne psihijatrije i psihoterapije. Dječija i adolescentna psihijatrija je deficitarna struka u Hrvatskoj, ali i izrazito preventivna, jer prevenira poremećaje u odrasloj dobi, odno- sno značajno umanjuje finansijski gubitak u odrasloj dobi (6). Poliklinika, odnosno ambulantni dio je jedan od najvažnijih dijela zavoda koji ima i najdužu vrijednu tradiciju. U ambulantnom dijelu se provode različite 10 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 7-15. dijagnostičke procedure, kao i različite vrste terapija. Ambulanta za predškolsku dje- cu obuhvata djecu dobi od 0 do 7 godina, a uključuje različite dijagnoze i terapijske metode, kao što je npr. dijagnostika autističnog spektra poremećaja, dijagnostika i terapija regulacijskih poremećaja (poremećaji jedenja, spavanja, eksesivno plakanje male djece). Ambulanta za obiteljsku, bračnu terapiju i psihodramu uključuje visoko diferentne metode liječenja pojedinaca, kao i cijelih porodica. Ambulanta za psihote- rapiju, psihosomatiku, liaison psihijatriju djece i mladeži obuhvata važan psihotera- pijski rad u polju emocionalnih i psihosomatskih poremećaja u širem smislu te riječi (povezanost psihološkog i tjelesnog), kao i službu za konzultativnu i liaison psihi- jatriju (povezanost naših stručnjaka s drugim Klinikama i s djecom/adolescentima koji imaju određenu tjelesnu bolest ili tjelesne probleme). Ambulanta za poremećaje jedenja djece i mladeži obuhvata važno područje dijagnostike i liječenja poremećaja jedenja, koja inače počinju u djetinjstvu. Ambulanta za psihoanalitičku psihoterapiju mladeži je posebno fokusirana na analitičko (psihodinamsko) liječenje adolescenta, u smislu emocionalnog i nagonskog razumijevanja adolescenta s njegovim proble- mom, kao i cijelom porodicom. Indikacija za liječenje u bilo kojoj specijalističkoj ambulanti ostvaruje se preko prvog pregleda specijaliste (6). Dnevna bolnica za mladež je prema svom konceptu također psihoterapijski ori- jentirana, i prima adolescente u dobi od 12 do 18 godina. U užem smislu, u dnevnoj bolnici se provodi multimodalni pristup i multimodalna terapija (kombinacija različitih terapija), od strane multispecijalističkog tima. Dnevna bolnica se, prema svom kon- ceptu, približava intenzivnom ambulantnom liječenju. Indikacije za dnevnu bolnicu su slične već prije navedenim indikacijama. U Dnevnoj bolnici za mladež provode se indi- vidualne psihoanalitičke i grupne psihoterapije, grupni tretmani koje vode rehabilitator i socijalni pedagog, terapijska tehnika psihodrame, edukativne i kreativne i druge vrste terapija. Porodične (obiteljske) terapije provode se s porodicama gdje postoji indikacija. Također, gdje je indicirano, provodi se i medikamentozni tretman s psihofarmacima. Provodi se sastanak terapijske zajednice svih pacijenata i članova tima Dnevne bolnice za mladež. Informacioni razgovori s roditeljima vode se prema potrebama (6). Stacionarni dio Zavoda je koncipiran psihoterapijski, što obuhvata jedan od rijetkih pristupa, kojim se problemi kod adolescenata pokušavaju rješavati psihološ- kim metodama, odnosno razgovorom, ali uz povremeno nužnu dodatnu medikamen- toznu terapiju, kao i druge metode (6). Ovaj odjel započeo je svoj rad 1. augusta 2014. godine. Do sada su bile pretež- ne indikacije na ovom odjelu adolescenti/ice s poremećajima jedenja, adolescenti s emocionalnim i depresivnim poremećajima, adolescenti skloni samopovređivanju te drugim poremećajima. S obzirom da se radi o stacionarnom odjelu „otvorenog tipa“, Zavod nije bio u mogućnosti do sada zbrinjavati adolescente u akutnim stanjima, akutno suicidalne, kao ni akutno psihotične. Indikacije za prijem na stacionarno li- ječenje su određene u skladu s mišljenjem cijelog tima, stručnim smjernicama, kao i arhitektonskim mogućnostima. Preliminirani rezultati pokazuju poboljšanje u oko 70% slučajeva. U 2013. godini ambulantno se liječilo 4424 pacijenta, a kroz dnevnu Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 11 Sabina Kučukalić et al.: Organizacija dječije i adolescentne psihijatrije bolnicu je prošlo 3232 pacijenata. U navedenom Zavodu zaposleno je 8 ljekara spe- cijalista psihijatrije/specijalista dječije i adolescentne psihijatrije uz 3 specijalizanta dječije i adolescentne psihijatrije. Pored navedenih, zaposleno je 8 medicinskih se- stara/tehničara, 2 defektologa, socijalni radnik i psiholozi (6). Ako u konačnici uporedimo dva dosta slična modela funkcionisanja: Odjel za dječiju i adolescentnu psihijatriju UKC Sarajevo i Zavod za dječiju i adolescentnu psihijatriju KBC Rebro Zagreb, uočavamo najprije primjetnu razliku u broju zapo- slenih, prije svega ljekara specijalista ali i ljekara na specijalizaciji. Generalno je broj medicinskog i nemedicinskog osoblja povoljniji u Zavodu, iako se broj pacijenata tretiranih u toku godine značajno ne razlikuje. Stanje u dječijoj i adolescentnoj psi- hijatriji se i u Hrvatskoj opisuje kao „teško“, a u Bosni i Hercegovini je stanje još teže. To naravno utječe, kako na sam tok poremećaja, na sve manju prevenciju i rano otkrivanje, tako i na kvalitet usluge. Ako ne posjedujemo dovoljan broj osoblja, a preopterećeni smo brojem pacijenata, onda pri tome najviše trpe djeca i adolescenti kojima je potrebna pomoć stručnjaka. Prikaz funkcioniranja: Klinika i poliklinika za dječiju i adolescentnu psihijatriju, psihosomatiku i psihoterapiju Wuerzburg – Njemačka 1. Dječiji odjel (16 pacijenata) 2. Adolescentni odjel (16 pacijenata) 3. Ambulanta (2500 pacijenata godišnje) 4. Intenzivna njega (14 pacijenata) 5. Klinika za duševno zaostalu djecu (15 pacijenata) 6. Dnevna bolnica (30 pacijenata) 7. Forenzički odjel 8. Škola u bolnici (7) Tabela 1: Tipični dnevni raspored u Dnevnoj bolnici za djecu i adolescente Wuerzburg, Njemačka 08:00 Dolazak u Dnevnu bolnicu 08:15 Zajednički doručak, pranje zuba 08:45-10:15 Škola, terapija, dijagnostika ili boravak u igraonici 10:15-10:30 Pauza-užina 10:30-12:00 Škola, terapija, dijagnostika ili boravak u igraonici 12:15-12:45 Zajednički ručak 12:45-13:30 Vrijeme za slobodne aktivnosti 13:30-14:00 Vrijeme za domaće zadaće 14:00-16:00 Grupna terapija (ergoterapija, likovna terapija, happy hour, izlet, motopedika) 16:00 Užina 16:15 Odlazak kući 12 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 7-15. Tabela 2: Najčešće dijagnoze kod prijema u bolnicu za dječiju i adolescentnu psihijatriju, psihosomatiku i psihoterapiju Wuerzburg, Njemačka ICD-10 Broj slučajeva Dijagnoza F 32 52 Depresivna epizoda F 90 30 Hiperkinetski poremećaj F 91 15 Poremećaji ponašanja F 43 12 Reakcija na teški stres i poremećaj prilagođavanja F 20 9 Shizofrenija F 06 <=5 Drugi duševni poremećaji uzrokovani oštećenjem i disfunkcijom mozga te tjelesnom bolešću F 10 <=5 Duševni poremećaji i poremećaji ponašanja uzrokovani upotrebom alkohola F 23 <= 5 Akutni i prolazna duševna oboljenja F 30 <= 5 Manična epizoda F 33 <= 5 Povratni depresivni poremećaj Terapijska ponuda na Klinici i poliklinici za dječiju i adolescentnu psihijatriju, psihosomatiku i psihoterapiju Wuerzburg, Njemačka: � Psihoterapija, � Socioterapija, � Muzikoterapija, � Terapija pokretom, � Ergoterapija, � Likovna terapija, � Logoped, � Terapija uz pomoć životinja (terapijski pas), � Trening roditelja, motopedika, � Terapeutsko penjanje, � Farmakološka terapija. U poliklinici zaposleno je 15 ljekara, 5 psihologa, 8 terapeuta, 2 socijalna radni- ka, 8 sekretarica i preko 40 medicinskih sestara/tehničara (7). Psihijatrijska bolnica za djecu i mladež – Zagreb Ova bolnica funkcionira kao samostalna ustanova. Sastavljena je iz sljedećeih odjela: � Specijalističko-konzilijarni odjel čine ambulante dječijih i adolescentnih psihija- tara, psihologa, logopeda-defektologa, neurologa i EEG laboratorij; uz to, ljekari obavljaju poslove u ambulanti pri Domu zdravlja; � Hitna ambulanta; � Dnevna bolnica čiji je kapacitet 40 stolica/kreveta za djecu od 5 do 18 godina; � Bolnički odjel je sastavljen od 37 kreveta (25 akutnih i 12 hroničnih) i podijeljen je na dva dijela smještena na dvije etaže. Omladinski dio ima 21 krevetu, a na njemu se liječe adolescenti u dobi od 15 do 18 godina. Dječiji dio ima 16 kreveta, a predviđen je za dobnu skupinu od 6 do 14 godina (8). Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 13 Sabina Kučukalić et al.: Organizacija dječije i adolescentne psihijatrije Od sredine 2015. godine u sklopu bolnice započela je sa radom Škola u bolnici. U Psihijatrijskoj bolnici za djecu i mladež je trenutno zaposleno 16 psihijatara od kojih dvanaest ima subspecijalizaciju iz dječije i adolescente psihijatrije, jedan ima subspecijalizaciju iz psihoterapije te jedan subspecijalizaciju iz socijalne psihijatrije. Uz ljekare, u bolnici rade 4 psihologa, 3 defektologa-logopeda, 1 radni terapeut, 1 socijalna radnica, 1 diplomirana medicinska sestra, 9 viših medicinskih sestara, i 26 srednjih medicinskih sestara/tehničara (8). Prednosti funkcionisanja dječije i adolescentne psihijatrije u sklopu Psihijatrijske klinike Prednosti funkcionisanja dječije psihijatrije u sklopu Psihijatrijske klinike su ma- nji troškovi, manji broj zdravstvenog osoblja, dežurstva su organizirana u sklopu psihijatrijske klinike, hospitalizacija je omogućena 24 sata dnevno kroz prijemnu ambulantu Psihijatrijske klinike, postoji saradnja i razmjena informacija sa ostalim psihijatrima unutar Klinike, te zajednička edukacija i zajednički projekti. Osim na- vedenog, koriste se usluge Intenzivne njege Psihijatrijske klinike za akutno psiho- tične adolescente sa agresivnim i destruktivnim ponašanjem. Koriste se usluge lo- gopeda, neuropsihologa, pedagoga, socijalnih radnika, ljekara specijalista iz drugih oblasti unutar UKC-a. Postiže se lakše, brže i jeftinije korištenje laboratorijskih i dijagnostičkih procedura. Prednost predstavlja i praćenje faktora rizika, toka bolesti, prognoze i liječenja od djetinjstva, pa kroz odraslu dob. Nedostaci funkcionisanja dječije i adolescentne psihijatrije u sklopu Psihijatrijske klinike Nedostaci funkcionisanja dječije psihijatrije u sklopu Psihijatrijske klinike su otpor roditelja da dovedu dijete na kliniku radi stigmatizacije i postavljanja dijagnoze, ma- njak kadra za obimniji timski rad, nedostatak prostora za formiranje specijalističkih servisa i ambulanti za različite poremećaje, nemogućnost razdvajanja dječijeg od adolescentnog odjeljenja, nedostatak materijalnih sredstava za realizaciju planskih aktivnosti unutar UKC-a. Zaključci 1. U većini razvijenih zemalja tretman djece i adolescenata sa psihičkim smetnjama odvija se kroz Klinike za dječiju i adolescentnu psihijatriju. 2. Analizom prednosti i nedostataka funkcioniranja dječije i adolescentne psihi- jatrije u sklopu Psihijatrijske klinike u Sarajevu, mišljenja smo da se još nisu stvorili uvjeti za osnivanje samostalne Psihijatrijske ustanove za djecu i adolescente. 14 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 7-15. 3. Za koncept organizacije samostalne Psihijatrijske ustanove za djecu i adoles- cente u Sarajevu neophodno je osigurati finansijska sredstva, odgovarajući prostor, opremu i stručni kadar različitog profila. 4. Da bi klinika za djecu i adolescente funkcionisala samostalno, neophodno je da minimalno posjeduje: intenzivnu njegu, prijemnu ambulantu, dva odvojena staci- onara za djecu i adolescente, dnevne bolnice i specijalizirane ambulante. Reference 1. Centers for Disease Control and Prevention. Mental health surveillance among children – United States, 2005-2011. MMWR. 2013;62 (Suppl; May 16, 2013):1-35. 2. Keller D, Sarvet B. Is there a psychiatrist in the house? Integrating child psychiatry into the pediatric medical home. J Am Acad Child Adolesc Psychiatry. 2013;52(1):3-5. 3. World Health Organization. Regional Office for Europe (homepage on the internet). Copenhagen. Available from: http://www.euro.who.int/en/health-topics/ noncommunicable-diseases/mental-health/data-and-statistics. 4. Thomas CR, Holzer CE 3rd. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9):1023-31. 5. Belfer ML. Child and adolescent mental disorders: the magnitude of the problem across the globe. J Child Psychol Psychiatry. 2008;49(3):226-36. 6. Klinički bolnički centar Zagreb (homepage on the internet). Zagreb. Available from: http://www.kbc-zagreb.hr/zavod-za-djecju-i-adolescentnu-psihijatriju psihoterapiju/. 7. Klinik und Poliklinik fur Kinder – u. Jugendpsychiatrie, Psychosomatik u. Psychotherapie (homepage on the internet). Wuerzburg (updated 2016 April 11, cited 2016 April 14). Available from: http://www.kjp.ukw.de/startseite.html. 8. Psihijatrijska bolnica za djecu i mladež. Zagreb. Available from: http://djecja-psihijatrija.hr/. Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 15 Sabina Kučukalić et al.: Organizacija dječije i adolescentne psihijatrije CHILD AND ADOLESCENT PSYCHIATRY AS AN INDEPENDENT INSTITUTION OR AS A PART OF ADULT PSYCHIATRY Abstract Objectives: To describe the current organisational model and to analyze future perspectives of the Child and Adolescent Psychiatry Division at the Psychiatric hospital University clini- cal centre Sarajevo. Background: The Division for Child and Adolescent Psychiatry at the Psychiatric hospital exists over fifty years. It is the only Child and Adolescent Psychiatry Division in the Federation of Bosnia and Herzegovina. Patients aged between 3-18 years are treated through inpatient, ambulant care and a day hospital. A counselling centre for children and parents is a part as well. For economical reasons and professional exchanges it is better for the Division to exist as a part of the Psychiatric hospital. The main disadvantages are the delayed start of treatment onset because of stigma. Methods: Compare the function- ing model of our division with other hospitals for children and adolescents with psychiat- ric disorders. Discusion: In most countries the treatment is organized through independent clinics. If we compare the organization of the Division UKC Sarajevo with the DivisionKC BC Zagreb we can conclude that they have similar work concepts. The most prominent and basic difference is seen in the number of the available workforce although UKC Sarajevo treat almost the same numbers of children and adolescents with a range of disorders. An even greater difference is seen if we compare the Division for child and adolescent psychiatry Sarajevo with an independent clinic, for example, the Psychiatric hospital for children and adolescents in Zagreb has 78 employees with different educational profiles. The Division in Sarajevo has only ten employees, although we treat the same number of patients. Conclusion: We can conclude that in future we should try to establish an independent hospital for children and adolescents. For this concept it is necessary to provide financial resources, a multidisci- plinary professional team, equipment and space which depends on the competent goverment institutions. Key words: child and adolescent psychiatry, perspectives, organization models. 16 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives DOI: 10.5644/PI2017.173.02 Original scientific article CURRENT STATE AND PERSPECTIVES OF CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOLOGY IN BOSNIA AND HERZEGOVINA Slobodan Loga, Nirvana Pištoljević, Emira Švraka, Vera Daneš, Bojan Šošić Committee for Research in Neurology and Psychiatry of the Department of Medical Sciences of the Academy of Sciences and Arts of Bosnia Herzegovina Corresponding author: Nirvana Pištoljević nirvana.pistoljevic@gmail.com English language: Nirvana Pištoljević Translator for Bosnian/Croatian/Serbian language: Adnan Arnautlija Language editor for Bosnian/Croatian/Serbian language: Amra Mekić Submitted: 2016, accepted: 2017, published: 2017 Abstract The goal of this research was to determine the current state of child and adolescent psy- chiatry and psychology in Bosnia and Herzegovina, and based on the findings, point out some possible future prospects in these fields. For this purpose, a questionnaire regarding the existing state of services provided in the child and adolescent psychiatry and psychology in the county was designed and disseminated across the country. The representatives of 18 dif- ferent governmental institutions (Psychiatric Clinics, Mental Health Centers, Health Clinics and Centers for Early Childhood Development) across Bosnia and Herzegovina completed the questionnaire. The data were collected from a total of 143 professionals and focused on minors, children ranging in age from birth through 18 years old. Professionals reported that 47.47% of their applied work with patients was with typically developing children, com- pared to working with children with special needs, where the average percentage across the institutions was 52.53%. A total of 143 experts who worked with the preschool children and minors reported that 35 of them (24.47%) worked directly with the children over 50% of their work-time, and 34 of them (23.77%) worked exclusively with children and minors. Based on the data collected and a descriptive analysis conducted, some recommendations were made for the future. Key words: child psychology, child psychiatry, Bosnia and Herzegovina, adolescent psychiatry. Introduction According to the World Health Organization (WHO) 15% of world population live with some form of disability, while the data from the World Bank (WB) indicate Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 17 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH that 20% of poorest world’s population have some form of special needs (1). Approximately, 1 out of 6 children in the USA has some kind of a disability (2). The CDC’s Children’s Mental Health Report published in 2015 suggested that more children have some form of psychiatric disorders than diabetes, cancer and AIDS combined, further more because of stigma that follows these conditions, these prob- lems were not adequately addressed and a large number of children with psychiatric disorders were in danger of school drop-out, substance abuse and juvenile delin- quency (3). Anywhere in the world, whether children are classified as having a de- velopmental disorder, psychiatric disorder or a disability, they all fall under “special needs” category and most will require some kind of support from Health, Education, and Social Care sectors. According to the USA data from 2013, Attention-Deficit/ Hyperactivity Disorder (ADHD) (6.8%) was the most prevalent diagnosis among children ages 3 to 17 years-old, followed by behavioral or conduct problems (3.5%), Anxiety (3.0%), Depression (2.1%), Autism Spectrum Disorders (ASD) (1.1%), and Tourette Syndrome (0.2%) among children ages 6 to 17 years) (3). Regarding the adolescents 12 to 17 years old, data showed that 4.7% were reported with illicit drug use disorder, 4.2% had alcohol abuse disorder, and 2.8% of adolescents had cigarette dependence (4). In 2008, results of a German National Health Survey study of the prevalence of mental health problems in children and adolescents, concluded that 14,5% of children and adolescents ages 7 through 17 years-old, could be classified as having one or more mental health problems (5). Also, the study found that fewer than half of those children and adolescents were receiving treatment and that the key is in the work on the prevention (5). According to the UNESCO’s reports, 98% of children with disabilities in de- veloping countries are not included in any form of formal education and 30% of world’s “street” children live with disabilities (6). As far as Bosnia and Herzegovina (B&H) are concerned, no National Survey of Heath exits, nor registry or connected system that tracks numbers of children and adolescents with developmental and/or mental health problems diagnosed or attending schools. UNICEF-B&H “Study of the Situation of Vulnerable Groups of Children and Policy Framework” estimated that 10% of population has some form of disability (7) but there are no data whether B&H is following the world trends in the prevalence of developmental delays and mental and developmental disorders in children and adolescents. According to the UNICEF, 9% B&H children are delayed in growth and development, and only about 13% of them have access to some form of pre-school education (8), thus having the opportunity to be detected as children with growth and development issues before they start school. This seems to be one of the major problems; children with disabili- ties in this country are “invisible” until they attend school, if they do, making early detection of disorders almost nonexistent. In 2013, UNICEF conducted a survey with 9% of the adult population of B&H on their attitudes towards children with disabilities (9). According to the results, all participants in the survey daily encountered children with disabilities and 33% stated 18 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. that they felt pity towards them; 57.9% of people believed that children with dis- abilities could not fully be included like other children regardless of personal effort and the efforts of their families and 80.0% believed that by providing professional support, a child with disabilities could be only partially included in the society (9). Stigma and discrimination of children with disabilities is present in all aspects of their lives and it is main obstacle for full inclusion in education, health care, public events and decision-making (10). Stigma of children with disabilities is prevalent throughout the world and something lots of research is focusing on. In some cultures stigma and discrimination is based in traditionally wrong concepts about causes of disabilities, for example connected with spiritual and/or religious bad omens and similar misconceptions (11). Stigmatic and discriminative attitudes toward disabili- ties and families of youth with disabilities “have important negative psychosocial consequences for individuals living with disabilities“(12) and there is connection with severity of disability and parental perception of stigmatization by their child’s disability (13). In B&H, 45% of people reported that they would not accept a child with intellectual disabilities as the best friend of their own child and 55% of popula- tion reported the use of violent forms of disciplining children and almost a third of the participants (30%) think that the main obstacle for better living conditions, de- velopment of children with disabilities and their inclusion in the society in B&H was the lack of well-trained professionals and institutions that deal with children with disabilities (9). This study focused on those professionals and the services they pro- vide. Based on the fact that majority of mental disorders occurred first during child- hood and adolescence, the necessity for strengthening preventive measures in form of early childhood detection and intervention services to decrease risk of secondary, severe mental disorders is obvious (14). Even though we know this from research and the conventions, B&H has no legal framework on early detection of disorders or organized system of intervention, and no prescribed system of services provided to support full inclusion of children and youth into the society. Services provided at the community level differ greatly location-to-location, and are not clearly regulated by any governmental agencies. There is a move towards deinstitutionalization and strengthening of the new service centers at the local level, Mental Health Centers, but they are still mostly incomplete as far as staffing (i.e. lack of psychiatrist, chil- dren’s psychiatrists, clinical or counseling psychologists, early childhood interven- tionist, etc.) and are still mostly not providing services to children and adolescents. In addition, programs for specialty and subspecialty in child and adolescent psychiatry or graduate level programs in child clinical, abnormal or developmental psychology do not exist in B&H. Therefore, many of the service providers for the children and the adolescents with disorders are not registered, supervised or need to pass any rigorous government base testing or licensing process in order to pro- vide therapeutic or other services. In 2001/2002 academic year, Medical School of the Sarajevo University in collaboration with the Umeå University organized a four semester joint Master’s degree program in Child and Adolescent Psychiatry Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 19 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH and Psychology. Thirty students, 18 psychiatrist and 12 psychologists, from all over the country entered the program and 24 have successfully graduated (15). These experts were to contribute advancement of services across B&H in child and adoles- cent psychiatry and psychology and contribute to the body of research coming from these related fields. To date, ten of them have received their Phd degrees as well, and therefore would be able to contribute to the academic programs development. Unfortunately, since the cohort form 2001/2002, no program in child/adolescent psy- chiatry or graduate programs in different subspecialty areas in psychology have been established nor offered at the universities. No more educated and trained profes- sionals have been produced and therefore, it would be logical to conclude that the fields of child and adolescent psychiatry and psychology are not being developed, but rather being extinguished in B&H. The goal of this research was to determine the current conditions, map the avail- able resources and the way they are utilized in the child and adolescent psychia- try and psychology in B&H. Surveys were sent to the graduates of the program in 2001/2002 and some additional Health Clinics and Centers where children and adolescents with disabilities would be referred to by the governmental norms and standards of the referral process. Based on the findings, we wanted to analyze the current state and point out possible future prospects in these fields for B&H. Method In order to collect relevant data on the current state of the child and adolescent psychiatry and psychology in B&H, a questionnaire was constructed on the actual services available for the children and adolescent with disorders/disabilities. The Committee for Psychiatric and Neurological Research of Academy of Science and Arts of Bosnia and Herzegovina designed the questionnaire, and it was disseminated via e-mail across over 60 relevant institutions in B&H. The non-standard question- naire is available to interested readers if they write to the authors. Since the services provided for children and adolescents with mental health or developmental disorders are center based, a team of professionals work with them while a psychiatrist or a psychologist is an integral part of the team. Therefore, we collected data on the treat- ments provided by all the members of the teams at each location. The service pro- viders could be a combination of any of the following professionals: psychiatrists, psychologists, neuro-psychiatrist, speech and language therapists, occupational ther- apist, physical therapist, special educator-rehabilitator, pedagogues, social workers and teachers, etc. A total of 18 institutions from 15 cities completed the questionnaires: Department of Psychiatry UKC Tuzla, Health Clinic/Center for Early Childhood Development Tuzla, Health Clinic Tuzla, General Hospital „prim.dr. Abdulah Nakaš“ Sarajevo, Public Institution „Division of Alcoholism and Substance Abuse“ Sarajevo, Health Clinic/Center for Mental Health Ključ, Center for Mental Health Široki Brijeg, 20 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. Department of Psychiatry UBKC Banja Luka, University Hospital Foča, Health Clinic/Center for Mental Health Prijedor, Health Clinic Drvar, Health Clinic Glamoč, Health Clinic Tešanj, Health Clinic/Center for Mental Health Derventa, Kindergarten Mostar, Center for Mental Health Brčko, Health Clinic Cazin (includ- ing Center for Mental Health, Center for Early Childhood development, Center for Physical Medicine and Rehabilitation), and Health Clinic Ljubuški. Figure 1 shows the above mentioned respondents that covered locations from both entities of Bosnia and Herzegovina: The Federation of Bosnia and Herzegovina (72% respondents), Republic of Srpska (22% respondents), and The Brčko District (6% respondents). With the data provided form the locations, a database using a program for statistical analysis SPSS (Statistical analysis in social science) was created and a descriptive statistical analysis was conducted. Figure 1 The questionnaire consisted of an open and close-ended questions about the institution, profiles of professionals employed, and their involvement in activities related to child psychology and psychiatry. The surveyed institutions had the pos- sibility of responding by choosing one of the provided answers and some descriptive data in addition. They reported detailed data on the numbers of professionals work- ing with minors with disabilities and disorders, time spent and type of treatment, and codes used to register minors in the institutions. In the questionnaire the following categories / codes were offered: F50 - Eating disorders, F51 - Nonorganic sleep disorders, F70-F79 – Intellectual disabilities, F80 - Specific developmental disor- ders of speech and language, F81 - Specific developmental disorders of scholastic skills, F82 - specific development disorder motor function, F83 - Mixed specific Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 21 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH developmental disorders, F84 - Pervasive Developmental Disorders (PDD), F88 - Other disorders of psychological development, F89 – Unspecified disorder of psy- chological development, F90 – Hyperkinetic disorders, F91 – Conduct disorder, F92 - Mixed disorder of conduct and emotions , F93 - Emotional disorders with onset specific to childhood, F94 - Disorders of social functioning with onset specific to childhood and adolescence, F95 – Tic disorder, F98 - Other behavioral and emotion- al disorders with onset usually occurring in childhood and adolescence, F99 - Mental disorder, not otherwise specified. Results Table 1 shows the detailed basic information on the institutions surveyed and their engagement time with minors. The institutions reported data on their geographical position and relevance to the population they were providing services for. Some of the institutions were registered at the level of the Entity (Federation of B&H, Republic of Srpska, Brcko District), serving much larger populations then Municipal institutions, serving much smaller populations. Distribution of surveyed institutions by B&H en- tity is presented in Figure 1. According to the registration level of the institution, the team members working with minors differed not just by the number but also by pro- files of professions (Table 1). Also, in Table 1 data were reported on the numbers of minors the institutions registered as patients in the year 2014 for the first time. Institutions provided services mostly (83.33%) to children ages birth through 18 years old. Only three institutions limited the age of the children they provided services for. Health Center / Center for Early Childhood Development Tuzla and the Kindergarten “Mostar” worked with children from birth to 6 years old while Public Health Centre/Center for Mental Health in Prijedor worked with children ages 6 to 18 years old. All of the 18 institutions reported that they work both with children with and without disabilities. As part of the questionnaire, included institutions es- timated percentage of team’s time engaged working with children and adolescents without disabilities. Three institutions did not provide answers to this question and 15 institutions that provided answers to this question averaged 47.47% of their time spend working with children without disabilities compared to 52.53% time spend working with children with disabilities. Results have ranged from the minimum specified percentage of 8% to the highest 90% of work time spend with children with special needs. Twelve out of 18 surveyed institutions reported data on the 1024 children and adolescents first time registered in their institution in the year 2014. Data showed that 88.9% institutions listed education/rehabilitation as their treatment they offer to children. 66.7% of institutions also held workshops for parents, and 18.8% held art workshops including art/music therapy, etc. Also, 83.33% of institutions reported that they work with children 1: 1, while only 52.9% of them used group as treatment setting (two or more children in the group). 22 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. Table 1 Ordinal number City Institution Geographycal area in activities Covered population of geographical area Nummber of minors first time registred in 2014 Team engagement in work with minors compared to adult patients ( % ) 1 Tuzla Department of Psychiatry UKC Tuzla Bosnia and Herzegovina, Federa- tion of Bosnia and Herzegovina, Canton, Community/Township 500.000 32 10% Health Clinic/Center for Early Childhood Development Tuzla Federation of Bosnia and Her- zegovin Canton, Community/ Township 130.000 100 100% Health Clinic Tuzla Community/Township not mentioned not men- tioned 50% 2 Sarajevo General Hospital „prim.dr. Abdulah Nakaš“ Sarajevo Canton 400.000 50 10% Public Institution „Division of Alcoholism and Substance Abuse“ Sarajevo, Canton 400.000 0 10% 3 Ključ Health Clinic/Center for Mental Health Ključ Community/Township 10.000 30 70% 4 Široki Brijeg Center for Mental Health Široki Brijeg International, Federation of Bosnia and Herzegovina, Canton, Community/Township 50.000 175 not mentioned 5 Banja Luka Department of Psychiatry UBKC Banja Luka Republic Srpska not mentioned not men- tioned not mentiond 6 Foča University Hospital Foča Republic Srpska 200.000 not men- tioned 100% 7 Prijedor Health Clinic/Center for Mental Health Prijedor Community/Township 100.000 50 30% 8 Drvar Health Clinic Drvar Community/Township 5.800 2 20% 9 Glamoč Health Clinic Glamoč Community/Township 2.500 150 1% 10 Tešanj Health Clinic Tešanj Community/Township not mentioned not men- tioned 30% 11 Derventa Health Clinic/Center for Mental Health Derventa Republic Srpska 3.500 not men- tioned 20% 12 Mostar Kindergarten Mostar Community/Township 60.000 130 95% 13 Brčko Center for Mental Health Brčko District Brčko 94.000 285 50% 14 Cazin Health Clinic Cazin (includ- ing Center for Mental Health, Center for Early Childhood development, Center for Physi- cal Medicine and Rehabilitation) Community/Township 68.000 not men- tioned 35% 15 Ljubuški Health Clinic Ljubuški Canton 30.000 20 70% * Detailed basic information on the institutions and their engagement time with minors ( preschool and schoolage chidren, and adolescents) * Detailed basic information on the institutions, time of their engagement in working with minors expressed in percentages, and the nummber of minors first time registred in 2014 in each institution Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 23 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH We also have collected the data on the number and profile of the experts who worked with minors (preschool and school age children and adolescents) at each institution (Table 2). The following results are also presented in Figure 2 with the Table 2 Professional profile Psychi- atrist Neu- ropsy- chiatrist Psychol- ogist Educator - rehabilitator Occupational Therapist Speech and Language Therapist Social worker Nurse Physical Therapist Total number of profes- sionals Number of specific professionals working with minors 12 15 19 9 4 10 10 59 5 143 The number of profesionals working with minors 50% of their work hours 2 2 9 4 1 3 5 7 2 35 The number of professionals working full time with minors (only) 2 2 2 5 0 6 0 17 0 34 * Number and type of professionals from relevant institutions across B&H, and the percentage of their time spent working with minors ( preschool and schoolage chidren, and adolescents). Figure 2 24 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. amounts of time each professional spent working with children exclusively (12 psy- chiatrists, 15 neuro-psychiatrists, 19 psychologists) Detailed data on the profiles of the professionals in teams at each institution and their time engaged working with preschool and school aged children and adolescents are presented in the Table 2. Totally 143 professional that work with preschool and school age children and ado- lescents were reported on, 35 of them (24.47%) worked with minors over 50% of their time, and 34 of them (23.77%) worked exclusively with minors (Figure 3). Data were also collected on the disorder categories according to the ICD-10 cod- ing system professionals in B&H use. Figure 4 details data about each code/disorder registered for minors enrolled in the institutions programs in 2014. 14 out of 18 institutions (77.8%) reported that they worked with minors registered under codes F70-F79 – Intellectual Disability, while 13 out of 18 institutions (72.2%) reported that they worked with minors registered under a code F80 - Specific developmental disorders of speech and language. 10 out of 18 institutions (55.5%) reported that they worked with minors registered under a code F81 - Specific developmental disorders of scholastic skills. 13 of 18 institutions (72.22%) reported that they worked with minors registered under a code F91 - Conduct disorders. 14 out of 18 institutions (77.8%) reported that they worked with minors registered under a code F92 - Mixed disorders of conduct and emotions, 14 out of 18 institutions (77.7%) reported that they worked with minors registered under a code F94 - Disorders of social function- ing with onset specific to childhood and adolescence. 12 of 18 institutions (66.7%) reported that they worked with minors diagnosed with F95 - Tic disorders More details are shown in Figure 4. Figure 3 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 25 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH Discussion According to the preliminary 2013 census data, B&H has a population of 3.791.662. Since 15 out of 18 provided numbers of patients that they cover with their activities in their geographical areas, totaling to a capacity for 1.523.800 people (40.2% of the whole population of B&H), we can conclude that the surveyed institutions were a representative sample. Based on the data from 18 surveyed institutions, the 2013 census data, and the data on the world’s trends, we were able to draw some conclu- sion and recommendations. We do know that 10 to 20% of children and adolescents in the world have some kind of mental health problem and that in low and mid- income countries their needs are neglected (16). B&H being a mid-income country approaching seriously the poverty line (every 6th household is considered poor by the world standards (7)),brings us to a conclusion that the state of special needs children and adolescents in B&H is likely to follow the world’s trends. Therefore, we are able to say that the study we conducted suggest that the current state and thus the perspec- tives of child and adolescent psychiatry and psychology in B&H are worrisome. Unfortunately, we were not able to get more precise data on the number of chil- dren and adolescent with special needs or the actual numbers of service providers or institutions providing services in the country. The complexity of the counties dif- ferent disenfranchised levels the government makes it impossible to collect precise data and provide a proper analysis of the situation. There are 14 Ministries of Health in a 3.8 mil people country. In addition, the country has no agency or one governing Figure 4 26 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. body to coordinate registries or all data collecting systems for tracking children and adolescents diagnosed or patients receiving treatments. Each canton or even mu- nicipality may have their own system, not communicating with other systems, or there is no system yet in place at all. Therefore, this study has many methodological shortfalls, which we are aware of and took them into the consideration. And, we can immediately say that B&H needs a centralized data collecting system in order to learn what are the needs of its population, comorbidity, prevalence of disabilities, what kinds of methodologies exist in the system, correct numbers of service provid- ers, and therefore be able to do better policy planning and conduct a reform of Health and Education sector at all 14 levels. Our data were collected on 143 professionals across 18 institutions that report- ed that they work with preschool, school age children and adolescents. 35 of them (24.47%) reported working with children over 50% of their total hours at work, and 34 of them (23.77%) worked exclusively with children and minors, which left us to conclude that 51,74% of professionals spend less than 50% of their work hours with children and minors. This showed a lack of treatment hours for children and adolescents, lack of “child-only” tailored services and departments in institutions. We know that 9% of children in B&H are delayed in growth and development (7), and that about 15% of population has some form of disability (1). Therefore, we can conclude that B&H has similar rates of disabilities, but the treatment hours reported by the professionals and the prevalence data from the world and B&H, raise a ques- tion of the intensity of treatments provided for the children detected. We also know from the WHO that in low and mid-income countries, which B&H is one of, 4 out of 5 people who need services for mental, neurological or substance use disorders, do not receive them (16), which is the trend these data confirm in B&H. The next question naturally raised then is the quality or the kind of the treatments these in- stitutions do offer. No evidence based validated screening instruments are standard- ized in B&H, so the well child health-checks are routine visit that we know are a weak opportunity for early detection of any disorders. These mandatory visits need to become something systematical with the use of validated screening tools, which would immediately aid in early detection and therefore prevention of severe lifelong disorders for many children. On the other hand, from the survey we know that most of the treatments provided are education-rehabilitation based, but we know that in the low and mid-income countries, most of the intervention in mental and neurological disorders are neither evidence-based nor of high quality (17). This makes us also emphasize the impor- tance of updating graduate programs training for the professionals and introducing novel research-based methodologies and validated assessment tools into practice. In addition to mandating validated instruments to be used in practice in order to detect, monitor and provide treatment for these vulnerable groups. Not all institutions worked with variety of disabilities and disorders. Though, it is important to mention that at each institution different teams of professionals existed, Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 27 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH and psychologists and psychiatrists might have been or not part of the teams at all. This made it difficult to focus only on child and adolescents psychiatry and psychol- ogy and to make clear conclusions for these professions. Uncontrolled variable in our study also was the fact that some professions are naturally focused on only few areas of difficulties, for example, speech and language therapists work with children having speech and language disorders primarily. Still, we found that institutions also reported that 55.5% worked with diagnosis code F83 (Mixed specific developmental disorder), 33.3% with F89 (Unspecified disorder of psychological development), and 22.22% with F99 (Unspecified mental disorder) and F88 (Other disorders of psychological development). This lead us to conclude that large numbers of chil- dren and adolescence are registered under non-specific and vague codes, which then makes it much more difficult to assign proper intervention, provide such appropri- ate treatments and track their advancement. The most interesting result is that 147 children and adolescent were registered for the first time in 2014 under the code of F80 (Phonological disorder), and that 72% of surveyed institutions mentioned that they work with children with this diagnoses. The prevalence of speech and language disorders in the world is high, in the USA around 18.8% of children ages 6 to 21 receive services under this category (18). This tells us that most of the institutions provide services mostly for youth with mild disabilities that affect language devel- opment and then actually devote majority of their time working with children that are typically developing and children with language and communication difficulties. WHO in the report issued in 2013 stated that mental, neurological and substance use disorders account for top ten leading causes of years lived with disability and 10% of the global burden of disease (19). The World Economic Forum in 2011 es- timated that in the next 20 years, global impact of mental disorders in terms of lost economic output will amount to US$ 16 trillion (20). This tells us what a significant concern not just public health wise, but also economic wise this is, and it provides again a red flag and proof for the importance of early detection and proper inter- vention at an early age. The guardians of public health, the government, needs to partner up with key stakeholders and have a leading role in the policy reform, de- stigmatization and rising awareness, increasing the quality of services provided and updating higher education and professional development for the service providers for children and adolescence with disabilities. Education on all levels is the key message. If we could educate the population and decrease stigma, therefore increase early detection and treatment as prevention of life long disabilities. In order to then strengthen the intervention and treatment, we have to educate professionals to use standardized tools to better detect, monitor and treat children and adolescents. The child and adolescent psychiatry and psychology should not dissipate in B&H, they should be advanced and given support as multidisciplinary approach to healthy de- velopment of every child. 28 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. Acknowledgement Authors of the paper would love to show their gratitude to Eldin Džanko and Stanislava Majuševic for their invaluable contribution to this research. Thanks are in order for all your feedback and help with data collection, communication with the locations throughout the country, in addition to the statistical analysis guidance. References 1. Who.int. [Home page on the Internet].Switzerland: World health Organization; c2015 [updated 2015 Oct 18, cited 2015 November 26]. Disability and health; [about 2 screens]. Available from: http://www.who.int/mediacentre/factsheets/fs352/en/ 2. Boyle C, Boulet S, Schieve L, Cohen R, Blumberg S, Yeargin-Allsopp M et al. Trends in the Prevalence of Developmental Disabilities in US Children, 1997-2008. Pediatrics. 2011;127(6):1034-1042. 3. Perou R, Bitsko R, Blumberg S, Pastor P, Ghandour R, Gfroerer J et al. Mental Health Surveillance Among Children — United States, 2005–2011. Centers for Disease Control and Prevention MMWR. 2013;62(2):1-35. 4. Ravens-Sieberer U, Wille N, Erhart M, Bettge S, Wittchen HU, Rothenberger A et al. Prevalence of mental health problems among children and adolescents in Germany: results of the BELLA study within the National Health Interview and Examination Survey. European Child & Adolescent Psychiatry. 2008;17(S1):22-33. 5. Cdc.gov. [Home page on the Internet] .USA: Centers for Disease Control and Prevention; c2015 [updated 2015 November 12, cited 2015 November 26]. CDC Features – Children’s Mental Health - New Report; [about 2 screens]. Available from: http://www.cdc.gov/ features/childrensmentalhealth/ 6. UN Office of the High Commissioner for Human Rights (OHCHR). Handbook for parliamentarians on the Convention on the Rights of Persons with disability: from exclusion to equality realizing the rights of persons with disabilities. Geneva (Switzerland): UN Office of the High Commissioner for Human Rights (OHCHR); 2007. 7. UNICEF Bosnia and Herzegovina. Study of the situation of vulnerable groups of children and policy framework and strategies that support the services of social protection and inclusion of children in Bosnia and Herzegovina - Situation Analysis. UNICEF Office for Bosnia and Herzegovina; 2011. 8. Pilav A, Lolic A, Abdelbasit A, Mitrovic D, Jokic I, Stijak M. Bosnia and Herzegovina Multiple indicator cluster survey 2011–2012. UNICEF Office for Bosnia and Herzegovina; 2013. 9. Dipa D, Fazlic S. Knowledge, opinions and experiences related to children with developmental disabilities - quantitative research findings. Sarajevo (Bosnia and Herzegovina): UNICEF Office for Bosnia and Herzegovina; 2013. 10. United Nations Children’s Fund. Children and young people with disabilities: Fact sheet. UNICEF New York; 2013. 11. The African Child Policy Forum. The African Report on Children with Disabilities: Promising starts and persisting challenges. Addis Ababa: The African Child Policy Forum (ACPF); 2014. 12. Green S, Davis C, Karshmer E, Marsh P, Straight B. Living Stigma: The Impact of Labeling, Stereotyping, Separation, Status Loss, and Discrimination in the Lives of Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 29 Slobodan Loga et al.: Child and adolescent psychiatry and psychology in BIH Individuals with Disabilities and Their Families. Sociological Inquiry. 2005;75(2):197- 215. 13. Gray DE. Perceptions of stigma: the parents of autistic children. Sociology of Health & Illness. 1993;15(1):102-120. 14. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology. 2011;21(9):655-679. 15. Loga S. Postgraduate study in CAPP in Sarajevo (2001-2003). In: Lagerkvist B, ed. Children and youth in the aftermath of war in Bosnia and Herzegovina. A joint master project on child and adolescent psychiatry and psychology between Sarajevo University and Umeå University. Report No 3:2008. Division of Child and Adolescent Psychiatry. Department of Clinical Sciences. Umeå University, Sweden. ISSN: 0349-0815. 16. World Health Organization. MhGAP Intervention Guide for Mental Neurological and Substance-use Disorders in non-specialized Health Settings. Geneva (Switzerland): World Health Organization; 2010. 17. Kieling C, Baker-Henningham H, Belfer M, Conti G, Omigbodun O, Rohde LA et al. Child and adolescent mental health worldwide: evidence for action. The Lancet. 2011;378(9801):1515-1525. 18. Heward WL. Exceptional children: an introduction to special education. 10th ed. Boston: Pearson; 2013. 19. World Health Organization. Investing in mental health: evidence for action. Geneva (Switzerland): World Health Organization; 2013. 20. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S et al. The Global Economic Burden of Non-communicable Diseases. Geneva (Switzerland): World Economic Forum; 2011. 30 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 16-30. TRENUTNO STANJE I PERSPEKTIVE DJEČIJE I ADOLESCENTNE PSIHIJATRIJE I PSIHOLOGIJE U BOSNI I HERCEGOVINI Apstrakt Cilj ovog istraživanja bio je da se utvrdi trenutačno stanje dječije i adolescentne psihijatrije i psihologije u Bosni i Hercegovini, a na osnovu nalaza, ukazano je na neke moguće perspekti- ve u budućnosti u ovim oblastima. U tu svrhu, dizajniran je i distribuiran upitnik u vezi sa po- stojećim stanjem usluga u dječijoj i adolescentnoj psihijatriji i psihologiji u zemlji. Upitnik su ispunili predstavnici 18 različitih državnih institucija (psihijatrijske klinike, centri za mental- no zdravlje, zdravstvene klinike i centri za rani razvoj kod djece) širom Bosne i Hercegovine. Podaci su prikupljeni od ukupno 143 stručnjaka i fokusirani su na maloljetnike, odnosno, djecu u dobi od rođenja do 18 godina. Stručnjaci su izvjestili da se 47,47% njihovog rada sa pacijentima odnosi na rad sa djecom sa tipičnim razvojem, dok je prosječni procenat rada sa djecom s posebnim potrebama za sve institucije iznosio 52,53%. Ukupno 143 stručnjaka koji su radili sa predškolskom djecom i maloljetnicima naveli su da je 35 njih (24,47%) radilo direktno sa djecom preko 50% radnog vremena, a 34 (23,77%) radilo je isključivo sa djecom i maloljetnicima. Na osnovu prikupljenih podataka i sprovedene deskriptivne analize, date su neke preporuke za budućnost. Ključne riječi: dječija psihologija, dječija psihijatrija, Bosna i Hercegovina, adolescentna psihijatrija. Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 31 DOI: 10.5644/PI2017.173.03 Review article DEVELOPMENT OF CHILD AND ADOLESCENT PSYCHIATRIC SERVICES IN CENTRAL EUROPE: HEALTH POLICY IMPLICATIONS OF THE SITUATION IN SWITZERLAND, GERMANY AND THE NETHERLANDS Klaus Schmeck1, Susanne Schlüter-Müller2 1Department of Child and Adolescent Psychiatry, Psychiatric University Hospitals Basel, Basel, Switzerland, 2Practice for Child and Adolescent Psychiatry, Frankfurt, Germany Corresponding author: Klaus Schmeck klaus.schmeck@upkbs.ch English language: Klaus Schmeck and Susanne Schlüter-Müller Translator for Bosnian/Croatian/Serbian language: Adnan Arnautlija Language editor for Bosnian/Croatian/Serbian language: Amra Mekić Submitted: 2014, accepted: 2016, published: 2017 Abstract Child and adolescent psychiatry is a young medical specialty that is in charge of mentally disturbed children and adolescents and their families. The discipline is in close contact with pediatrics and general psychiatry as well as with psychology, educational sciences and social work. In the core of child and adolescent psychiatry are the developmental perspective and the social psychiatric approach that integrates the family system and other relevant psycho- social systems like school or peer-groups. Developmental psychopathology approaches are the basis of all etiological explanations of child psychiatric disorders. In central Europe, child and adolescent psychiatry has evolved in different ways. Switzerland has the highest concentration of child and adolescent psychiatrists worldwide and, as a con- sequence, is focused mainly on individual psychotherapeutic approaches. In Germany, the number of child and adolescent psychiatrists has been insufficient for a long period of time so that the approach is more focused on social psychiatry where a child and adolescent psychia- trist leads a team of psychologists, social pedagogues and social workers. In the Netherlands 32 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 31-40. child and adolescent psychiatry is clearly focused on evidenced based medicine, but has been taken out of the medical system in 2015 and has become part of community care together with social work and therapeutic pedagogy. In many Balkan countries child and adolescent psychiatry has a long tradition but the number of child and adolescent psychiatrists is low in comparison to western and central European countries. Currently there are many threats that endanger child and adolescent psychiatry as an independent and powerful medical specialty that is of high relevance to compete the va- rious challenges for children and adolescents in modern societies and especially in societies in transition. Key words: child and adolescent psychiatry, social psychiatry, developmental psychopatho- logy. Introduction In contrast to general psychiatry child and adolescent psychiatry (CAP) is committed to both a developmental and a multi-professional approach. The concepts of deve- lopmental psychopathology (1) and the knowledge of greater chances for changes in childhood and adolescence are of high importance. The basis of the multi-profe- ssional treatment approach is a bio-psycho-social comprehension of diseases (2), which integrates besides biological/medical also psychological and social factors in the etiology of a disorder. Therefore educational and social sciences are closely connected to CAP (3). The majority of child and adolescent psychiatrists implement this bio-psycho- social approach in their daily work where educational and socio-psychiatric methods are as important as psychotherapeutic or pharmacotherapeutic interventions. As the majority of our patients (still) live with their families it is essential to include parents in the treatment (4), a second huge difference to the approach of general psychiatry. Equifinality (many different early experiences / life events can lead to the same psychological disorder) and multifinality (the same early experiences / life events can be followed by different developmental outcomes) (5) are fundamental princi- ples of developmental psychopathology that guide child and adolescent psychiatric concepts of etiology. The view of infantile development as an interaction between caregivers and child and therefore the interplay between them for the etiology of mental disorders makes it easier to move away from simple assignments of guilt. Furthermore results of longitudinal studies show that even an accumulation of seve- ral psychosocial risk-factors do not necessarily lead to a mental disorder (6, 7). The other way round children without severe psychosocial risk-factors can show – be- cause of infantile factors like difficult temperament, hyperactivity and impulsivity – emotional and behavioral difficulties, which can overstrain the family. Even „good enough“ or competent parents can seem to be pathological under the stress of a child with severe psychopathology. Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 33 Klaus Schmeck, Susanne Schlüter-Müller: Child and adolescent psychiatric services in central Europe Child and adolescent psychiatry in Europe Child and adolescent psychiatry (CAP) is a young medical specialty that is in charge of mentally disturbed children and adolescents and their families. As children rely on the support of their families or institutions that take care of them a social psychiatric approach is essential. The family system and other relevant psychosocial systems like school or peer-groups have to be integrated in the treatment. Therefore, the mul- tidisciplinary approach connects CAP with pediatrics and general psychiatry as well as with psychology, educational sciences and social work. A second cornerstone of CAP is the developmental perspective. The integration of developmental psychology and child psychiatry was the origin of developmental psychopathology, where the methods and approaches of normative developmental psychology are used to disen- tangle the etiology and course of mental disorders. It was already in 1954 that child and adolescent psychiatrists from diffe- rent European countries came together in a little town of Switzerland to develop a medical society which was finally founded in 1960 under the name of “Union of European Paedopsychiatrists”. In 1983 the organization changed its name into “European Society for Child and Adolescent Psychiatry (ESCAP)”. ESCAP aims “to promote mental health of children and adolescents in Europe, to increase quality of life among children and families and to ensure children‘s right for healthy deve- lopment and wellbeing” (8). The European Union of Medical Specialists (UEMS; http:// www.uems.eu), that has been founded in 1958, is an organization that coordinates the training of medi- cal doctors in more than 50 medical disciplines in 34 European countries. Of the Balkan countries Greece, Slovenia and Bulgaria are full members of the UEMS, Croatia is an associate member. The aim of UEMS is to set standards for high quality healthcare practice that are transmitted to the authorities and institutions of both the EU and the national medical associations in order to stimulate them to implement the recommendations of the UEMS in their healthcare system. In the “Standards of Postgraduate Medical Specialist Training” UEMS descri- bes the following training requirements for the specialty of child and adolescent psychiatry: 34 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 31-40. Table 1 Theoretical knowledge to be acquired by trainees of CAP (9) 1. Has advanced knowledge of normal child development from infancy and milestones. Knows how the child´s development can be distorted by abnormal biological, psychosocial and environmental influences, risk and protective factors. 2. Thorough knowledge of child and adolescent safeguarding and a comprehensive knowledge of the legal framework of the practice of child and adolescent psychiatry including relevant international conventions such as UN Convention on the Rights of the Child (1989) and the European Union Agenda for the Rights of the Child (2007). 3. Masters knowledge and skills to evaluate and handle acute child and adolescent psychiatric conditions. 4. Advanced knowledge of assessment, using a biopsychosocial approach, investigation and the use of international diagnostic systems (ICD and DSM), medical treatment and follow up, course and prognosis of child and adolescent disorders. 5. Advanced knowledge of pharmacological treatment of child and adolescent psychiatric conditions 6. Sound knowledge of psychological and a range of psychotherapeutic treatment methods 7. An understanding of paediatrics, particularly paediatric neurology and rehabilitation 8. Knowledge and understanding of advances in medical technology that are relevant to child and adolescent psychiatry 9. An understanding of adult psychiatric conditions, particularly in young adults and parents 10. An understanding of drug and alcohol misuse and its comorbidity with child and adolescent psychiatric conditions 11. An understanding of environmental influences on child and adolescent psychiatric conditions from conception to adulthood to include: pregnancy, family, child maltreatment, housing, neighbourhood, media (e.g. computer use, social media networking, gambling), school climate and other environmental stressors. 12. An understanding of forensic psychiatry including its organisation and duties, both criminal and civil frameworks of justice. In table 2 there is an overview of the current situation (2012) of child and ado- lescent psychiatry and psychotherapy (CAPP) in European countries. The number of CAPP specialists varies enormously between the countries from 3217 children and adolescents per CAPP specialist in Switzerland to 75’000 children and adolescents per CAPP specialist in Poland. Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 35 Klaus Schmeck, Susanne Schlüter-Müller: Child and adolescent psychiatric services in central Europe Table 2 Child and adolescent psychiatry in European countries UEMS (2013). The status of child and adolescent psychiatry in European countries (unpublished) The current situation in Germany With more than 150 child and adolescent hospitals, clinics and departments, more than 100 outpatient departments and more than 600 CAPs working in private prac- tice (10) the child and adolescent psychiatric patient-centered care is currently on a high standard in Germany. In Germany there are three different ways of outpatient child and adolescent psychiatric assessment and treatment. Attached to most child and adolescent psychia- tric hospitals are outpatient departments that are subsidized with high flat-rates with the intention that they should take care of the most disturbed patients from difficult psychosocial backgrounds. Beside child and adolescent psychiatrists who work in individual settings and who are mostly focused on individual psychotherapy the- re is a third approach to child and adolescent psychiatric patient-centered care that is called “social psychiatry agreement”. This agreement between medical doctors and insurance companies allows an interdisciplinary work in a child and adolescent psychiatric private practice to offer a competent alternative and addition to inpatient treatment. In those private practices CAPs are obliged to employ a staff of social-pedago- gues and social workers with special training in any kind of therapeutic work (not a full psychotherapy training) as well as psychologists. The difficult question if a men- tally disturbed child or adolescent needs more pedagogic or more psychiatric help 36 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 31-40. can be answered with “he or she needs pedagogic help because he/she is a child that has to be educated and psychiatric help because he/she is a patient” and can therefore “lead from a coexistence to a cooperation” (11) of educational and psychiatric care. This implicates the knowledge, that only with the know-how of different professions mentally ill children and adolescents can be helped in a sustainable way. Child and adolescent care in structures of social-psychiatric practices is local and low-threshold work. A central task is the connection between somatic, psychiatric and social assessment for integrative therapeutic interventions. In such a practice many of the duties are taken over by the non-medical co-workers: Assessment: 1. Neuro-psychiatric Assessment 2. Broad Assessment of development and social behavior, including observation in social environment (school, Kindergarten) 3. Assessment of interactions und relationships as well as biographical history including observation of the patient in contact with his/her parents, care-givers and environment 4. Specific testing (psychological, developmental, capability/disability etc) Therapy: 1. Establishment of an individual therapeutic program (medical and non-medical) 2. Consultation and psycho-education of the parents 3. Interventions during psychosocial crisis including contacting school, agencies, social welfare office/youth welfare office 4. Therapeutic pedagogic and developmental activities Cooperation outside the practice with: Pediatricians, speech-therapists, physi- otherapists, social welfare offices, hospitals etc., Kindergarten, schools, children’s homes, foster parents, lawyers, guardianship court etc. Through inclusion of the social environment the resources of the patient and his family can be used to strengthen the therapy process. The current situation in Switzerland Switzerland has one of the longest traditions of child and adolescent psychiatry in the world. It was the Swiss Moritz Tramer who was elected as the first president of the new society “Union of European Paedopsychiatrists” in 1954 (12). Since then child and adolescent psychiatry has developed into a strong medical specialty so that today (2013) in Switzerland there are more child and adolescent psychiatrists (N=650) than for example neurologists (N=530), gastroenterologists (N=326) or on- cologists (N=293). With about 1.5 million children and adolescents under the age of 19 living in Switzerland (total Swiss population: nearly 8 million inhabitants) one Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 37 Klaus Schmeck, Susanne Schlüter-Müller: Child and adolescent psychiatric services in central Europe child and adolescent psychiatrist takes care of about 2300 children and adolescents in the population, what can be seen as the highest concentration of child and adoles- cent psychiatrists worldwide (13). About 500 CAPs work in private practice, another 200 work in hospitals or are in training. With this high amount of CAPs working in private practice there is a long tradi- tion of individual psychotherapy as standard approach. Patients with more complex psychiatric disorders or from difficult psychosocial backgrounds are mostly sent to outpatient departments of child and adolescent psychiatric hospitals which have, as a tradition, closer links to pediatric hospitals than in other countries. These figures could lead to the misestimation that Swiss CAP is in a state of paradise. However several problems have to be mentioned: • More than 70% of the Swiss child and adolescent psychiatrists are older than 50 years. This will lead to serious problems in the next decade when those doctors will retire. • Currently it is difficult to attract young doctors for a specialization in our field. As a consequence, Swiss child and adolescent psychiatric hospitals have major difficulties to fill vacancies of medical doctors and have to engage psychologists instead. • Most child and adolescent psychiatrists work in private practices (alone or with general psychiatrists or psychologists) and don’t see more than about 50 patients per year. Psychodynamic approaches with frequent sessions are common so that even with an enormous number of CAP specialists it is difficult to get severely ill children and adolescents into specialized treatment. The current situation of CAP in Switzerland can only be understood against the background of extremely high numbers of specialists and the long tradition of indivi- dual psychotherapy. Such a system of care can only work in a rich country with high expenses for specialized medical care. For most European countries and especially for the Balkan countries this model should not be transferred because a transfer would lead to a split between high standards of care for a small group that can afford these treatments and a large number that can’t. As long as there is no fair distribution of resources between countries there should be a strong focus on fair distribution of resources inside a country. The current situation in the Netherlands Over the last decades the Netherlands had established one of the most developed standards of care for children with mental problems. Nine out of 14 child and ado- lescent psychiatric hospitals are located at university centres and the quality of sci- entific research is among the best internationally. Therefore it is no surprise that a great emphasis has been put on changing the system to an evidenced based system of care. Cognitive behavioural psychotherapeutic approaches are most popular, and the scientific approaches are strongly focused on biological research. 38 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 31-40. However, despite this high level of care and research the Netherlands have radi- cally changed the way in which child and adolescent psychiatric services are pro- vided to children and adolescents. As of Jan 1st 2015 CAP has been taken out of the medical system (health insurance) and, despite massive opposition, is now under the responsibility of the civil authorities in the local communities. This decision is unique in Europe and has terminated child and adolescent psy- chiatry as a medical specialty. More important, it threatens the delivery of appropri- ate mental health care for children in the Netherlands. It is difficult to understand why children with mental disorders are treated differently from minors with somatic complaints. The gap between child and adolescent psychiatry and adult psychiatry that is a concern in many countries will become much bigger so that the pathway of care across the lifespan will be disrupted for these mentally disordered children. Conclusions for the development of child and adolescent psychiatry in Bosnia and Herzegovina In Bosnia and Herzegovina child and adolescent psychiatry has a long tradition but currently the number of child and adolescent psychiatrists is very low in comparison to western and central European countries. There are many threats that endanger child and adolescent psychiatry as an independent and powerful medical specialty that is of high relevance to compete the various challenges for children and adoles- cents in modern societies and especially in societies in transition (4). The transition process in general and especially the war in Bosnia and Herzegovina have broken up societal structures and lead to severe traumatisation of many children and adolescents. In contrast to the enormous need for help the number of facilities and trained personnel in child psychiatric settings is far too low. One of the major problems of child and adolescent psychiatry in Bosnia and Herzegovina is the fact that CAP is not a medical speciality but still a subspecialisa- tion of general psychiatry. As a consequence the core decisions concerning the development of child psychiatry are taken by the management of the general psychiatric hospitals. This is especially true for the employment of new young professionals and the training they will get. To explain and stress the importance of promoting child and adolescent psychiatry as a profession is a long lasting struggle of those very few who work in the field (14). Training in child and adolescent psychiatry should become a more important issue for the medical system in Bosnia and Herzegovina. After a master course in 2002-2004 which was organized by the Medical Faculty of the University of Sarajevo in collaboration with the Medical Faculty of the University of Umea (Sweden), there was no other training in child psychiatry in Bosnia and Herzegovina. For the further development of CAP in Bosnia and Herzegovina it is essential that the BiH Society of Child and Adolescent Psychiatry applies for membership Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 39 Klaus Schmeck, Susanne Schlüter-Müller: Child and adolescent psychiatric services in central Europe in the UEMS so that the UEMS can help to implement international standards of training. As a first step the Swiss Society of Child and Adolescent Psychiatry has decided to support the attendance of BiH delegates in the annual UEMS meetings. References 1. Cicchetti D, Rogosch FA. A developmental psychopathology perspective on adolescence. Consult Clin Psychol. 2002;70(1):6-20. 2. Resch F. Entwicklungspsychopathologie des Kindes- und Jugendalters. Weinheim: Psychologie Verlags Union; 1996. 3. Schmeck K. Bezugsdisziplinen der Kinder- und Jugendpsychiatrie. In: Fegert JM, Schrapper Ch, editors. Handbuch Jugendhilfe-Jugendpsychiatrie. Weinheim und München: Juventa; 2004. p. 251-7. 4. Daneš-Brozek V. Contemporary characteristics of the developmental age psychopathology. Psychiatr Danub. 2012;24(Suppl.3):384-7. 5. Cicchetti D, Rogosch FA. Equifinality and multifinality in developmental psychopathologyEquifinality and multifinality in developmental psychopathology. Development and Psychopathology. 1996;8(4):597-600. 6. (6)Laucht M, Esser G, Schmidt MH. Developmental outcome of infants born with biological and psychosocial risks. J Child Psychol Psychiatry. 1997;38(7):843-53. 7. (7) Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003;18;301(5631):386-9. 8. (8) ESCAP [homepage on the Internet]. Aims and goals of ESCAP [cited 2014 Mar 21]. Geneve: European Society for Child and Adolescent Psychiatry – ESCAP. Available from: http://www.escap.eu/index/aims-and-goals. 9. (9) UEMS. Training Requirements for the Specialty of Child and Adolescent Psychiatry. European Standards of Postgraduate Medical Specialist Training. Unpublished final draft of chapter 6 [cited 2014 Mar 21]. UEMS; 2013. Available from: http://www.uemscap.eu/. 10. Berufsverband für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie in Deutschland e. V. und Bundesarbeitsgemeinschaft der Leitenden Klinikärzte für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie e.V. [cited 2014 Mar 21]. Available from: http://www.kinderpsychiater.org/. 11. Fegert JM, Schrapper Ch, editors. Handbuch Jugendhilfe-Jugendpsychiatrie. Weinheim und München: Juventa; 2004. 12. ESCAP [homepage on the Internet]. History of ESCAP [cited 2014 Mar 21]. Available from: http://www.escap.eu/index/history. 13. SGKJPP. Gegenwart und Zukunft der Kinder- und Jugendpsychiatrie in der Schweiz [cited 2014 Mar 21]. Available from: http://www.sgkjpp.ch/SGKJPP/user_upload/documents/ Fachleute/Ki_u_Ju_Psychiatrie_Bericht_an_BAG_definitiv.pdf. 14. Daneš-Brozek V. Child and adolescent psychiatry in Bosnia and Herzegovina. In: Schmeck K, Schlüter-Müller S, Goth K, Daneš-Brozek V, Polnareva N, Suli A, et al. Improving the situation of children with psychiatric disorders in Southeast Europe. Application to the SCOPES research program of the Swiss National Science Foundation. 2011. p. 22-5. 40 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 31-40. RAZVOJ PSIHIJATRIJSKIH USLUGA ZA DJECU I ADOLESCENTE U CENTRALNOJ EVROPI: IMPLIKACIJE SITUACIJE U ŠVICARSKOJ, NJEMAČKOJ I HOLANDIJI NA ZDRAVSTVENE POLITIKE Apstrakt Dječija i adolescentna psihijatrija je mlada medicinska specijalnost koja je zadužena za djecu i adolescente sa mentalnim poteškoćama i njihove porodice. Ova disciplina je u bliskom kontaktu sa pedijatrijom i općom psihijatrijom, kao i sa psihologijom, obrazovnim naukama i socijalnim službama. U srži dječije i adolescentne psihijatrije su razvojna perspektiva i so- cijalni psihijatrijski pristup koji integrišu porodični sistem i druge relevantne psihosocijalne sisteme, poput škole ili vršnjačkih grupa. Razvojni psihopatološki pristupi su osnova svih etioloških objašnjenja psihijatrijskih poremećaja kod djece. U Centralnoj Evropi, dječija i adolescentna psihijatrija evoluirala je na različite načine. Švicarska ima najveću koncentraciju dječijih i adolescentnih psihijatara u svijetu i, kao posljedica toga, usredsređena je uglavnom na individualne psihoterapeutske pristupe. U Njemačkoj, broj dječijih i adolescentnih psihijatara nedovoljan je već duži vremenski period, tako da je pristup više usmjeren na socijalnu psihijatriju gdje dječiji i adolescentni psihijatar vodi tim psihologa, socijalnih pedagoga i socijalnih radnika. U Holandiji, dječija i adolescen- tna psihijatrija se jasno fokusira na medicinu zasnovanu na dokazima, ali će biti izvučena iz medicinskog sistema u 2015. godini i postat će dio njege u zajednici, zajedno sa socijalnim radom i terapijskom pedagogijom. U većini balkanskih zemalja dječija i adolescentna psihijatrija ima dugu tradiciju, ali je broj dječijih i adolescentnih psihijatara nizak u poređenju sa zemljama Zapadne i Centralne Evrope. Trenutno postoje mnoge prijetnje koje ugrožavaju dječiju i adolescentnu psihijatriju kao nezavisnu i snažnu medicinsku specijalnost koja je od velike važnosti za borbu sa razli- čitim izazovima za djecu i adolescente u savremenim društvima, a posebno u društvima u tranziciji. Ključne riječi: dječja i adolescentna psihijatrija, socijalna psihijatrija, razvojna psihopato- logija. Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives 41 DOI: 10.5644/PI2017.173.04 Professional article CHILD AND ADOLESCENT MENTAL HEALTH SERVICES CLINICAL ACADEMIC GROUP AT THE MAUDSLEY HOSPITAL IN LONDON Gordana Milavić Maudsley Hospital, South London and Maudsley NHS Foundation Trust, London Child and Adolescent Psychiatry Section of the World Psychiatric Association Corresponding author Gordana Milavić gmilavic@hotmail.co.uk English language: Gordana Milavić Translator for Bosnian/Croatian/Serbian language: Adnan Arnautlija Language editor for Bosnian/Croatian/Serbian language: Amra Mekić Submitted: 2014, accepted: 2016, published: 2017 Abstract Objective: This article is based on the lecture delivered at the scientific meeting of the Academy of Sciences and Arts of Bosnia and Herzegovina, Department of Medical Sciences and UNICEF meeting on ‘Child and Adolescent Psychiatry and Psychology in Bosnia and Hercegovina – current status and perspectives’ held in Sarajevo from 5 - 7th April 2014. Materials and methods: The focus is on the need to prioritise the provision of mental health services for children and young people. Results: A brief history and description of the de- velopment of Child and Adolescent Mental Health Services in the UK, and specifically in England is provided. National Policy and clinical Guidelines are highlighted. A model of Child and Adolescent Mental Health Services (CAMHS) at the South London and Maudsley NHS Foundation Trust is described as an example of good practice. Conclusions: Evidence based interventions and proven service models should inform all planning. Collaborative decision making in clinical practice, an emphasis on quality standards and outcomes are at the core of well run services. The views of children, young people and their families are cru- cial in establishing new services. Transition to adult mental health services will require clear pathways and protocols. Key words: mental health services, children, adolescents. 42 Child and adolescent psychiatry and psychology in Bosnia and Herzegovina-state and perspectives Special editions ANUBiH CLXXIII, OMN 50, p. 41-49. Background There has been evidence of rising prevalence rates of childhood and adolescent men- tal health disorders across cultures and countries (1). More than half of all adults with mental health problems are diagnosed in childhood. Less than half were treated appropriately at the time (2). As many as three quarters of adult disorders stem from childhood (3). Although there are few studies which collate epidemiological data across the world (4, 5) it is likely that most mental, behavioural and developmental disorders across cultures start in childhood and adolescence (6). It is estimated that in the UK as many as 20 % of young people will suffer from mental health problems before they reach the age of 18 (7). More recent data in the UK point to ever increasing rates with 1 in 10 children and young people aged 5 - 16 suffering from a diagnosable mental health disorder (8). As many as 1 in every 12 and 1 in 15 ,children and young people respectively, are self-harming and the rate of admissions for self harm has risen by 68% over the last 10 years. (9). Children raised in care and the young offending population appear to be even more at risk (10, 11). The number of young people aged 15-16 with depression nearly dou- bled between the 1980s and the 2000s (12) and the proportion of young people aged 15-16 with a conduct disorder also doubled between 1974 and 1999 (13). The History of Child and Adolescent Mental health services The history of CAMHS in the UK can be traced back to the Child Guidance move- ment which originated in the USA at the turn of the century. The model was trans- ferred in the 1950-ies to the UK although in the annals of the Maudsley Hospital it is recorded that Dr William Moodie, the Deputy Medical Superintendent of the Maudsley Hospital set up a children’s department at the Maudsley Hospital in 1928. With the establishment of community and hospital outpatient services in the early 1970 - ies child and adolescent psychiatry drew closer to the study and practice of adult mental health provision. With the establishment of academic child and adoles- cent psychiatry the practice became more aligned with mainstream medicine. Over the last 10 years CAMH Services in the UK underwent some of the largest organisational changes since the inception of the services. Following the publica- tion of the National Service Framework for Children, Young People and Maternity Services (14) which established standards for promoting health and wellbeing in children and adolescents comprehensive CAMHS were developed up and down the country. The structure of CAMHS CAMHS can be managed as part of a Mental Health Trust together with Adult Mental Health Services, or are part of Acute Hospital Trusts, or Community Trusts. Some Child and adolescent psychiatry and psychology in Bosnia