Comment
6 Walsh J, Warren K. “Selective Primary Health Care: An Interim Strategy for
Disease Control in Developing Countries,” N Engl J Med 1979; 301: 967–74.
7 Jacob KS, Patel V. Classification of mental disorders: a global mental health
perspective. Lancet 2014; 383: 1433–35.
8 Heath I. Commentary: There must be limits to the medicalisation of human
distress. BMJ 1999; 318: 439–40.
Behavioural and emotional problems in preschool children
In what appears to be the first epidemiological
survey in Africa addressing preschool children’s
behaviour, caregivers in rural Kenya1 reported high
rates of preschool children (420 [13%] of 3273) with
behavioural and emotional problems; 338 (10%) of
3273 had externalising problems and 728 (22%) of 3273
had internalising problems. Historically, behavioural
and emotional problems in preschool children have
often been disregarded or considered to be transient
aspects of children’s emerging autonomy. However,
longitudinal evidence has shown that preschool children
with behavioural and developmental problems are at
increased risk of mental health problems throughout
childhood and adolescence, particularly if they have
co-occurring internalising and externalising problems.2
The consistent patterns from preschool through to
adulthood are consistent with the life course perspective
of early child development,3 supported at least partially
by neuroscientific evidence showing that during the
preschool period, brain development is sensitive to the
detrimental effects of poverty and adverse childhood
experiences4 and to the beneficial effects of maternal
support.5 Advances in future work can build on current
findings1 and address gaps in knowledge about
behavioural and emotional problems in preschool
children in Africa, including cultural and methodological
considerations of measuring behavioural problems, risk
factors, and prevention.
Given the small number of studies of preschool children
in Africa, identification of valid assessment methods for
behavioural problems might be difficult. Adaptions of
the Child Behaviour Checklist (CBCL) have shown good
psychometric properties in previous work done by Symon
Kariuki and colleagues in Kenya. In a study of the CBCL
in over 44 societies,6 the two African countries included
in the sample were among those with the highest total
problem scores and Ethiopia’s item ratings correlated
least well with those of other countries. The assessment
of preschool children’s behavioural and emotional
www.thelancet.com/psychiatry Vol 4 February 2017
9 WHO, Calouste Gulbenkian Foundation. Social determinants of mental
health. Geneva, World Health Organization, 2014.
10 Jacob KS. Reducing suicide rates: need for public health and population
interventions. Indian J Psychol Med 2016; 38: 510–13.
problems could be improved by identifying behavioural
problems from a local cultural perspective. Such efforts
Mauro Fermariello/Science Photo Library
with adolescents in East Africa7 found that local mental
health terms for some domains, such as depression,
map onto those used in existing tools, but are expressed
differently. In other domains, such as conduct problems,7
a new scale might be needed rather than adaption of
existing measures.
In addition to cultural considerations, none of the
questionnaires routinely used to measure children’s See Articles page 136
behavioural and emotional problems are intended for use
with adults with low educational levels. Although reading
items to parents might overcome illiteracy, minimally
educated parents of preschool children have been shown
to have lower expectations about developmentally
normative behaviour, compared with better educated
parents, particularly in rural settings.8 There is little
information about whether the psychometric properties
of questionnaires vary by parental education.
Direct assessments of children’s executive function
abilities, which are related to emotional regulation, might
provide a useful supplement to parent questionnaires,
particularly in preschool children. Although much of
the executive functioning research has been done in
developed countries, executive function measures for
preschool children can be translated and successfully used
in African contexts.9
Kariuki and colleagues showed that perinatal events
and medical history, especially seizures, increase the risk
of behavioural and emotional problems in rural Kenya.1
Other risk factors that are particularly relevant to
preschool children in Africa include maternal depressive
symptoms, psychosocial deprivation, food insecurity,
and violence exposure.
Work on the prevention of preschool children’s
behavioural and emotional problems in Africa could
build on emerging global evidence of effective strategies,
ranging from child protection laws and prevention of
maternal mental health problems to community-based
89
 Comment
parenting programmes and early child enrichment
preschool programmes.10 Recommended parenting
practices include responsive caregiving, early learning,
and attention to children’s health, nutrition, and safety
and security.3 Foster care has been shown to mitigate
some of the negative effects of severe psychosocial
deprivation, particularly in children placed before the
age of 2 years.11 The potential of global benefits from
prevention and treatment is high, given the prevalence
of behavioural problems in preschool children in Africa.1
Leaders from throughout the world, including Africa,
have implemented the Sustainable Development
Goals (SDGs) with the objectives of ending poverty and
promoting equity by 2030 through economic growth,
education, health, social protection, job opportunities,
and environmental protection. Ensuring adaptive
behaviours in preschool children can promote a workforce
of the future with the health, intelligence, creativity, and
altruism necessary to advance the agenda of the SDGs.
As the leaders of the WHO, UNICEF, and the World Bank
Group have written, “reaching children in the early years
is a prerequisite for sustainable development”.12 With
additional strategies to reduce risk factors associated with
preschool children’s behavioural problems, to promote a
nurturing and supportive environment, and to identify
and treat children with behaviour problems, we increase
the likelihood of achieving the SDGs globally.
*Maureen M Black, Matthew C H Jukes,
Michael T Willoughby
RTI International, NC 27709, USA (MMB, MCHJ, MTW); and
Department of Pediatrics and Department of Epidemiology and
Public Health, University of Maryland School of Medicine
Baltimore, MD, USA (MMB)
mblack@peds.umaryland.edu
Transitioning mental health into primary care
Health-care systems in low-income and middle-income
countries have not adequately responded to the
substantial burden linked to mental health, resulting in
enormous treatment gaps and major shortcomings in
the delivery of mental health care. Peru is no stranger
to this issue, and has attempted to implement several
measures to improve mental health care over the past
50 years. However, these measures have been hampered
by a combination of factors, including their small
90
We declare no competing interests.
Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY-NC-ND license.
1 Kariuki SM, Abubakar AA, Kombe M, et al. Burden, risk factors, and
comorbidities of behavioural and emotional problems in Kenyan children:
a population-based study. Lancet Psychiatry 2017; 4: 136–45.
2 Bornstein MH, Hahn C-S, Suwalsky JT. Developmental pathways among
adaptive functioning and externalizing and internalizing behavioral
problems: cascades from childhood into adolescence. Appl Dev Sci 2013;
17: 76–87.
3 Black MM, Walker SP, Fernald LC, et al. Early childhood development
coming of age: science through the life course. Lancet 2016; published
online Oct 3. http://dx.doi.org/10.1016/S0140-6736(16)31389-7.
4 Noble KG, Houston SM, Brito NH, et al. Family income, parental education and
brain structure in children and adolescents. Nature Neurosci 2015; 18: 773–78.
5 Luby JL, Belden A, Harms MP, Tillman R, Barch DM. Preschool is a sensitive
period for the influence of maternal support on the trajectory of
hippocampal development. Proc Natl Acad Sci U S A 2016; 113: 5742–47.
6 Rescorla L, Ivanova MY, Achenbach TM, et al. International epidemiology of
child and adolescent psychopathology II: integration and applications of
dimensional findings from 44 societies. J Am Acad Child Adolesc Psychiatry
2012; 51: 1273–83.
7 Ng LC, Kanyanganzi F, Munyanah M, Mushashi C, Betancourt TS.
Developing and validating the youth conduct problems scale-Rwanda:
a mixed methods approach. PLoS One 2014; 9: e100549.
8 Williams PD, Williams AR, Lopez M, Tayko NP. Mothers’ developmental
expectations for young: children in the Philippines. Int J Nurs Stud 2000;
37: 291–301.
9 Abubakar A, Holding P, Van Baar A, Newton CR, Van de Vijver FJ, Espy KA.
The performance of children prenatally exposed to HIV on the A-Not-B task
in Kilifi, Kenya: a preliminary study. Int J Environ Res Public Health 2013;
10: 4132–42.
10 Petersen I, Evans-Lacko S, Semrau M, et al. Promotion, prevention and
protection: interventions at the population- and community-levels for
mental, neurological and substance use disorders in low- and
middle-income countries. Int J Ment Health Syst 2016; 10: 30.
11 McLaughlin KA, Fox NA, Zeanah CH, Nelson CA. Adverse rearing
environments and neural development in children: The development of
frontal electroencephalogram asymmetry. Biol Psychiatry 2011; 70: 1008–15.
12 Chan M, Lake A, Hansen K. The early years: silent emergency or
unique opportunity? Lancet 2016; published online Oct 3.
http://dx.doi.org/10.1016/S0140-6736(16)31701-9.
scope or scale, insufficient political support, and poor
organisation and allocation of human resources.1
Historically, mental health care in Peru has been
relegated to and centralised at the tertiary care level,
which meant the availability of treatment was restricted
to three psychiatric hospitals in Lima, the capital city
of Peru. In 2011, only 0·27% of Peru’s health budget
was assigned to mental health, 98% of which was
assigned to these three institutions.2 In 2014, of the
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