FLORENCE DECLARATION
Mental wellbeing of children in Europe
Plans and perspectives
XIII ESCAP Congress
Florence, Italy
August 25-29, 2007

1. Preamble
This Declaration was adopted during the XIII European Society for Child and Adolescent Psychiatry (ESCAP) congress, held in Florence, Italy, August 2007, attended by the leading experts in the field. The conference discussed the current state of European child psychiatry and put forward recommendations as how to improve children' mental health; strengthen the effectiveness and the efficiency of treatments;  ameliorate the accessibility and the quality of services; and finally, overcome stigma and protect children human rights.

It is consistent with the UN Declaration of the Rights of the Child, the Geneva Declaration of the Rights of the Child, the UN Convention on the Rights of the Child, the WHO Mental Health Declaration For Europe and Mental Health Action Plan  for Europe, and the EC Green Paper on Mental Health. By adopting these documents, Member States have committed themselves to promote the mental health of all children and adolescents and ensure that mental health policies include as priorities the mental health and wellbeing of children and adolescents.  Member States have committed themselves to develop and make available and accessible mental health services that are sensitive to the particular needs and human rights of children and adolescents, operated in close collaboration with families, schools, day-care centres, neighbours, extended families and friends. They recognise the right of children with disabilities and/or mental health problems to enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child's active participation in the community, as well as grant effective protection from abuse and neglect.

2. Roots of child and adolescent psychiatry in Europe
European child psychiatry arises from a dynamic coexistence of different theoretical models and approaches. A common basis is the culture of human rights: child and adolescent psychiatry in Europe is inspired by the deep respect of children's rights. By valuing these approaches and building on their strengths, while sharing a strong commitment to a shared value system, it has proved possible to develop a versatile model of child psychiatry, able to  provide the means to prevent and cope with psychological and psychiatric difficulties by offering interactive and holistic interventions at community, family and individual levels.

The European tradition also involves the social and public field, aiming at creating networks of many agencies which all contribute to the support of young people on the basis of their needs, irrespective of age, gender, social or cultural background. In Europe, child psychiatrists respect individual differences, not only in the therapeutic realm, but also in the areas of public mental health addressing promotion and prevention.

Child and adolescent psychiatry is strongly linked to other neighboring disciplines such as pediatrics, neurology, psychiatry and psychology and to many other activities targeted at the child's physical and mental health, such as pedagogy, rehabilitation, speech therapy and physiotherapy. This interdisciplinary work is fundamental for prevention, treatment and research in the field of developmental age.

The 3rd Millennium Europe wants to be more and more open to new and different cultures.  Migration from neighboring as well as from more distant countries  requires our systems  to be more flexible in order to respond to new cultures and habits.  The aim of European child psychiatry is to integrate harmoniously  these populations and to enrich  their  cultures.

3. The scale of the problem
Europe is facing massive challenges in child and adolescent mental health. Fortunately most people in Europe enjoy a high quality of life: according to the World Health Organization (WHO, 2001), 80% of young people report a good psychological well-being. However, one  adolescent out of  five  has cognitive, emotional and behavioral difficulties and one  adolescent out of  eight suffers from a diagnosable mental disorder, and the prevalence is increasing decade by decade. Suicide associated with depression, substance abuse, eating disorders, conduct disorders, attention deficit hyperactivity disorders (ADHD) and post traumatic stress disorder (PTSD) in children are all deserving concerted action.  Developmental psychiatric disorders  rarely have a spontaneous remission and may cause difficult social adaptation or mental disorder in adult life if not early diagnosed and treated.
 
Child mental health is important in its own right, but it has also to be considered in the context of a lifespan approach: most adult mental disorders find their origin in childhood and adolescence and require early intervention and treatment. Mental disorders prevented in childhood  are mental disorders prevented for life.

4. The treatment Gap
Provision of services and the number of child psychiatrists varies very widely across European countries, ranging from one per 5,300 people under the age of 20 to one per 51,800 for the same population group. Countries of the European Union markedly differ in the organization of children and adolescents mental health services and in the content and organization of child psychiatry training. Little information is available about health and social investment into child and adolescent mental well being, but all indicators strongly suggest that child and adolescent mental health in most European countries is receiving a relatively small proportion of funding within mental health, which in turn receives  a low investment from  general  health investment, on average only 5.6%.  Investing in the mental health of children and adolescents is the most cost-effective intervention, aiming at preventing the burden of mental health problems in all age groups, and lowering the personal suffering and loss of productivity at individual, family and population level throughout the lifespan.

5. Developing responses
Recognizing the needs of children, adolescents, families and communities of Europe, and backed up by the evidence developed by European experts, the signatories of this declaration believe that European countries, regions and municipalities, supported and advised by intergovernmental agencies such as the Council of Europe, the European Commission and the World Health Organization, in partnership with NGOs including ESCAP, should all endorse the following actions that will assure the optimal mental well-being of young people:

Services and pathways to care
The core of our commitment is a reduction of the institutional approaches of care, which engender social exclusion. On the contrary it is essential to improve the quality of life of people with mental ill health or disability through social inclusion and the protection of their rights and dignity. The availability of services, mostly at the community-based level, helps patients and their families have an immediate and individualized answer to their needs. We believe that social and medical systems need to integrate their specific fields of action, with the well-being of the person as their central objective. This requires:
Planning adequate community mental health services for all ages, adequately staffed by well trained professionals working as multidisciplinary teams and integrated in primary health care.
Developing community mental health services for the whole lifespan ensuring comprehensiveness and continuity of care, especially for the severely mentally ill, monitoring the patient's transition from child psychiatric care to adult psychiatric care.
Monitoring and evaluating the utilization, the quality and the effectiveness of existing services.

Interventions
We want to offer effective and timely interventions, accessible to everyone on the basis of his/her need, balanced by the investment of evidence-based primary and secondary prevention by:
Applying interventions, both preventive and therapeutic, grounded on reliable and valid evidence; research findings should be implemented in clinical practice.
Basing  good practice on a mix of skills and approaches. Single-theory approaches should be avoided.
Creating a European-wide formulary for the use of psychopharmacological medications with children and adolescents.

Prevention
We believe that the essential first step for addressing mental ill health is prevention. Promotion of mental health and well being relies primarily on prevention strategies, which should focus on individual, family, community and social determinants of mental health, both by strengthening protective factors (e.g., resilience) and reducing risk factors (primary prevention). This can be achieved by:
Developing programmes in school settings, where children spend large parts of their time. Examples include school approaches targeting psychological well-being life skills and bullying prevention.
Identifying  mothers at risk of post-natal depression through nurses' home visits.
Teaching  parenting skills to at risk families in order to improve child development.
Supporting anti-stigma programmes that target social awareness and support the social inclusion of the patient and his/her family.
Allocating appropriate funding, according to the needs and resources in each country.

Human rights
We believe that services, intervention and prevention have all to be placed within a general framework which gives primary value to the respect for human rights and for diversity, including the rights of children and adolescents. Mental health cannot be imposed. It requires:
Planning  and developing actions with the active involvement of parents or legal tutors.
Empowering children and adolescents in ways appropriate to their age and development.
Assessing needs in a way which is sensitive to the cultural background and diversity of children, families and communities.

Training
We believe that the training of young child psychiatrists and researchers represents a fundamental element for the growth of our discipline, and that greater partnership across Europe will benefit the quality of research and practice. Research funding should increasingly cross boundaries thereby achieving Added Value for Europe. We support this by:
Achieving  a greater cohesion in training goals and methods for Child and Adolescent Psychiatry in Europe  as the knowledge in the field of children and adolescents mental health is constantly evolving and international activities are increasing.
Stimulating the implementation of best practices and the application of latest scientific data by regular professional update.
Encouraging  multi-disciplinary practice by shared training.

Research and Information
We believe that the common values of European child and adolescent psychiatry demand greater coordination of information and research, providing benefit to all participants. Experiences of one country increasingly are of value elsewhere. This requires:
The harmonization of existing national and international indicators on child and adolescent mental health and disability, in order to create a comparable dataset across Europe.
The stimulus of international research by committing research funding to multi-centre studies.
The setting up of a mechanism for applying international studies to local circumstances.

The undersigned commit themselves to working in partnership towards the development of an Action Plan for Child Mental Health in Europe that will put in effect the recommendations that are contained in this Declaration.  

ESCAP   WHO  etc

References

1 Declaration of the Rights of the Child, Proclaimed by General Assembly resolution 1386(XIV) of 20 November 1959, http://www.unhchr.ch/html/menu3/b/25.htm
2 Geneva Declaration of the Rights of the Child, Adopted 26 September, 1924, League of Nations, http://www.un-documents.net/gdrc1924.htm
3 Convention on the Rights of the Child,  UN Document Series Symbol: ST/HR/UN Issuing Body: Secretariat Centre for Human Rights, Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989
ENTRY INTO FORCE: 2 September 1990, in accordance with article 49
4 Mental Health Declaration for Europe. WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solution., Helsinki, Finland, 12–15 January 2005 (http://www.euro.who.int/document/mnh/edoc06.pdf, accessed 20 December 2006).
5 Mental Health Action Plan for Europe. WHO European Ministerial Conference on Mental Health: Facing the Challenges, Building Solution., Helsinki, Finland, 12–15 January 2005 (http://www.euro.who.int/document/mnh/edoc07.pdf, accessed 20 December 2006).
6 Green Paper. Improving the mental health of the population: Towards a strategy on mental health for the European Union.European Commission, Health and Consumer Protection Directorate-General,Brussels,2005,COM(2005)484 (http://ec.europa.eu/health/ph_determinants/life_style/mental/green_paper/mental_gp_en.pdf, accessed 20 December 2006).

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ESCAP Declaration of Hamburg 1999

Research in Child and Adolescent Mental Health

The European Society of Child and Adolescent Psychiatry (ESCAP), formerly the European Union of Pedopsychiatrists, was founded in 1960 to further knowledge and understanding in the field of child and adolescent psychiatry. This field includes emotional, psychosomatic and behavioural disorders, (including depression, anxiety and conduct problems), developmental disorders, such as autism, learning difficulties, and alcohol and drug problems in this age group. ESCAP is the only scientific organisation bringing together all European psychiatrists who practice with children and adolescents. It holds a regular conference, on this occasion to be held in Hamburg, Germany, in September, 1999, and publishes a quarterly professional, academic journal, ECAP (European Child and Adolescent Psychiatry).

The purpose of this declaration by ESCAP is to draw attention to the lack of resources for the conduct of research into child and adolescent psychiatric disorders. These disorders are the most common handicapping conditions in childhood. Epidemiological studies in different European countries suggest that around 10% of children and adolescents suffer from a psychiatric, developmental or learning disorder in any one year. These disorders have a major social and psychological impact on the child and family. The financial costs arising from their occurrence are considerable and fall not only on health, but also on social, education and voluntary services, and on the families themselves. For example, it has been estimated that conduct disorders, affecting around 5% of the child population, cost approximately 150,000 Euro per affected person during childhood, adolescence and early adult life. The personal suffering caused to children for example by depressive disorders (often with suicidal ideas and sometimes suicidal behaviour), eating disorders such as anorexia nervosa and bulimia, autism (with profound difficulties in communication and personal relationships), and mental retardation cannot be over-estimated.

Over recent years, and especially during the last twenty five years, there have been major advances in the understanding of child and adolescent psychiatric disorders. It has, for example, become apparent that many disorders of childhood, especially conduct disorders, but also depression and anxiety, frequently persist into adult life. Indeed, some adult psychiatric disorders, such as antisocial personality disorders, virtually always begin in childhood. The causes of some disorders have, to a considerable degree, been elucidated and we now know a great deal more about the way social and genetics factors interact to produce behaviour and emotional disorders. However, the gaps in our knowledge remain profound. For many disorders our understanding of causation remains limited. This is particularly true of depressive and anxiety disorders. There has been a very modest amount of research into the effectiveness of treatment, yet all are agreed that it is vital that the scarce resources that are available should provide treatment that is evidence-based. Evaluation of preventive initiatives has scarcely begun, although the social and financial rewards for successful prevention would be enormous.

The volume of financial support invested in European research into child and adolescent psychiatric disorders remains extremely low. Apart from the drug and alcohol field there appears to be no priority at all accorded in EC planning for research and development in child and adolescent psychiatry. National governments support studies to a variable extent, but, in general, there is a lack of financial and manpower resources to conduct research. ESCAP wishes to press the case for significantly more resources to be put into this important area of work.
More specifically, ESCAP strongly recommends:

1. Research into child and adolescent psychiatry identified as a priority area in the list of EC priorities for research.
2. Specific research support for studies into the treatment of childhood and adolescent depression, anxiety disorders, developmental disorders and conduct disorders.
3. Earmarked EC expenditure of 30 million Euro per annum for the next five years for the field of child and adolescent mental health research.
4. The commissioning by the EC of a review of existing research into child and adolescent psychiatric disorders currently being conducted in EC countries.
5. The establishment of EC training fellowships in child and adolescent psychiatry to increase the numbers qualified to conduct research in this field.