urces.

     From the perspective of the health sector, the setting in which its immediate actions will take
place is the area of the health services, which can play a double role with regard to the mental health
of children in acting as elements of health care per se and, paradoxically, as iatrogenic agents.

     The emotional equilibrium of mothers and children who are seeking health care is often
threatened by situations that arise in the health services.  Certain attitudes and behavior on the part of
the suppliers of the services and the general environment in many centers, where treatment is brusque
or the human rights of the patients are openly violated, sometimes succeed in producing emotional
imbalance. 



     




     The various mental health activities that make up the plans and programs should not be
developed monolithically in the manner of highly centralized vertical programs.  To the contrary, they
should be incorporated horizontally as elements of already existing child health programs, especially
as elements of maternal and child programs, and programs for the health of preschool and
schoolchildren.  At the same time a close relationship to the existing child care programs in other
sectors will be promoted, particularly with regard to education.

     Throughout the meeting several priority subjects considered to be of a priority nature were
discussed in the understanding that they do not exhaust the inventory of problems and conditions that
affect the mental health of children, although by virtue of their importance they deserve to be
considered among the foremost priorities.  They constitute points of departure that can serve as a basis
for the development of proposals for drafting the Plan of Action.

     The tentative nature of the proposals brings to light the general tone it is desired to imprint on
the Plan, whose preparation will not consist merely of the formulation of rigid canons but will rather
form part of a process of consultations, revisions, and reapproximations over the next two years.

     An abbreviated version of the presentations that served as a point of departure for the discussions
is contained in the annexes of the present report.  A summary is provided below of the most outstanding
points of the debate:


     Diagnosis of the Situation

     The information available in Latin America on the programs is insufficient to make an
approximate diagnosis, much less an accurate evaluation, of the situation of the mental health of
children, either with regard to the most important problems or to the services provided to care for them.

     The impression given by the specialized publications and general health reports is that at the
present time no specific programs exist for the mental health of children.  It may be affirmed with
relative certainty that national or provincial programs with defined structures and systematized actions
do not exist, although it is possible to identify actions and isolated programming elements in a very
small number of health services that could be considered to constitute mental health care.

     Thus, in several countries mental health considerations have been introduced into prenatal control
service, delivery care, and the management of high-risk deliveries.  In other countries infant stimulation
has been incorporated into maternal and child health programs.  Isolated mental health actions have also
have been carried out in programs for nutritional surveillance and family planning and in community
activities related to the extension of coverage of the general health services.  Evaluation of the maternal
and child health programs in the Hemisphere generally have to do with physical health care and, with
certain exceptions, do not emphasize the psychosocial aspects of maternal and child health.

     With regard to the most prevalent problems, some epidemiological research on mental health in
the general population in the 1960s included questions on the problems of children, and the results led
to the conclusion that a relatively high prevalence of mental retardation exists, both organic and
functional.  Subsequently, a few studies were carried out on the prevalence of epilepsy in the school
population that indicate surprisingly high rates, in some cases higher than 2% of the population studied. 
Child development studies have generally accentuated physical considerations.  Some studies have been
carried out on family dynamics, emphasizing the small amount of stimulation received by children in
the lower income strata and the consequent impairment of their social and cognitive development. 
More information is available in the education sector, especially with regard to school failure and
desertion, and to a lesser degree to learning and behavior problems.  However, generally speaking, the
health sector does not manage such information nor has it undertaken broad programs of cooperation
with the school system.


     Primary Prevention and Promotion

     Promotion of the mental health of children and primary prevention of psychosocial development
disorders, emotional imbalances, and mental disorders in children was dealt with throughout the
meeting and especially referred to in the working groups.  It was pointed out that the psychosocial
development of children does not end with adolescence, although there is evidence that the first six
years of life are critical to child development and that emphasis should consequently be given during
this period to actions to prevent imbalances and promote optimal development.

     The importance of global policies was underscored, particularly with reference to economic
policies and the consequences for the mental health of the family and children of the restrictions
imposed in most of the countries by the economic readjustment measures that have been carried out,
which have been largely the consequence of the external debt.  Note was taken of the importance of the
legal framework, which influences the daily lives of families and has a decisive effect on the mental
health of mothers and children.  Attention was also drawn to the need for analyzing the sociocultural
aspects involved, especially with regard to the practices followed in rearing children and to certain
attitudes and beliefs particularly prevalent in the Region.

     The existence of numerous prevention measures of proven effectiveness was repeatedly
mentioned, although it was considered desirable to weigh the cost/benefit ratio of each, both in
proposing them and in evaluating them.  

     Among the interventions considered, great importance was assigned to those capable of being
incorporated into programs for family planning, prenatal care, immunization, disaster preparedness,
prevention of malnutrition, and accident prevention.

     Some aspects of general health care that take place outside the health facilities can incorporate
effective prevention and promotion actions at low cost with proven effectiveness, as, for example, house
calls and of school health programs.


Role of the Family

     The family as a determining factor in the mental health of children was an important item on the
agenda; it was also considered repeatedly in discussing other subjects during the meeting.

     The subject of the dissolution of marriages and its social and economic consequences-
-which are mostly negative for mothers and children--was examined in detail, and the promotion of
legal protection measures was suggested.  The Group also formulated other recommendations to prevent
harm, including the identification of couples at risk, the training of health workers to carry out concrete
interventions, the development of educational programs, and, as in other aspects of the Plan, the
adoption of legislative measures.

     The effects of dysfunctional couples and the adverse consequences on children of abandonment
of the home by one of the parents were debated widely.  The provision of psychological counseling and
care services for couples with problems was another one of the recommendations formulated.

     Physical and psychological abuse of mothers and children was analyzed with respect to its effects
on the mental health of the victims and the need for providing specific assistance and for promoting
protection and rehabilitation measures. 

     The role of mothers is customarily underscored as the key element in promoting the psychosocial
development of children, thereby ignoring the role performed by fathers in this process.  It has been
suggested, accordingly, that the programs consider both partners of the couple in educational initiatives
oriented to promotion and prevention as well as in direct care when it is indicated.

     Among the measures for the promotion of mental health and primary prevention based on family
life are the sharing of tasks between the spouses, house-call services, and the granting of paid leave
from work for both parents on the occasion of births and adoptions in the family.

     It should be pointed out that the activities prescribed in this field precede birth and continue
beyond adolescence; consequently, they should be initiated before conception and even before
formation of the couple.


     Role of the School

     The school plays a determining role in the psychosocial development of children.  Unfortunately,
the conditions prevalent in the school system in most of Latin America are not propitious to optimal
development.

     The training of teachers is almost always a cause of controversy, and studies are generally
lacking on what the most appropriate training should be in view of the heterogeneous situations of the
countries.  As a rule, teachers do not receive any training or field experience with regard to the mental
health of children.

     Teachers not only are poorly trained but in practice are forced to develop curricula within a short
period of time, teach a large number of classes, and be subjected to numerous administrative controls. 
The parents, whose opinion as a rule is not required by the school system, cannot make their voices
heard with regard to the educational process, and still less are they able to intervene actively and
contribute along with the educators in processes that are not strictly academic, such as in the promotion
of mental health.

     A high proportion of the children who begin primary education do not finish it, and the number
of school desertions before the third grade is high.  A substantial portion of the population therefore
remains in a state of semi- or total illiteracy.  Under such conditions adequate psychosocial development
is threatened, and a socially and economically disadvantageous situation is created for the future of the
child.  School desertion is associated with patent risks for mental health, as is demonstrated by the high
proportion of school dropouts revealed by surveys carried out on inhalers of solvents, prostitutes,
common delinquents, and the perpetrators of violent acts.

     An appreciable portion of the school population in the Region, which in some cases may reach
as much as 10%, demonstrate learning problems.  However, the educational system does not have
facilities for evaluating these children nor does it provide services for assisting them.  It was
recommended that these deficiencies be remedied, and that in the case of children with learning
problems, that their cultural particularities, their native languages, and their home conditions be taken
into account when they are evaluated in order to ensure that cultural deterioration is not interpreted as
a lack of intelligence. 

     In general, the schools do not possess the equipment and facilities necessary for the promotion
of academic development, such as libraries, data processing, and periodicals. 

     Despite the apparent cultural uniformity of Latin America, the product of Spanish and Portuguese
colonization, the Region is home to a multitude of cultural groups, scattered in a mosaic of communities
that use different languages, are in various stages of development, and have disparate degrees of
technological development.  A particular case is that of the indigenous peoples, many of them
monolingual, for whom the school systems, with certain exceptions, do not provide.  But other
marginalized groups also exist who are not necessarily indigenous and who also live in a state of
abandonment or neglect. 

     The conditions outlined above produce great educational differences, both at the hemispheric
level and within the countries.  Only in exceptional cases have experiments been carried out in which
the modalities of the educational system have been adapted to the characteristics of the various
population groups.  In general it may be said that the Latin American educational system is undergoing
a crisis, determined in part by the economic situation.  There is a predominant trend toward the
decentralization and privatization of teaching that has resulted in progressive abandonment by the State
of its responsibility in the field of education.



     Communications Media

     The influence of the mass communications media on the mental health and psychosocial
development of children is a matter of great concern.  Although these media could be utilized as
instruments to promote and develop mental health, the use that is being made of them at the present
time has, on the whole, produced negative effects.  Of particular interest is the influence of television,
whose effects on the behavior of children and the thought patterns it conveys were strongly underscored
during the meeting. 

     The contents of television programs, in which violence, the consumption of mind-altering
substances, and promiscuous sexual behavior predominate, not to mention the constant encouragement
of consumerism and the introduction of cultural distortions, cannot fail to leave an impression on the
minds of children who are exposed daily, in many cases for hours at a time, to the messages of this
communications medium.  Children can and in fact often do imitate the violence and sexual behavior
shown in television programs and thus generally become familiarized with the lifestyles represented.

     On the other hand, it must not be forgotten that television is a socializing factor which, although
competing with family life and with school activities, can also provide an effective environment for
education and for the promotion of mental health.  In order to achieve this end it is necessary to
undertake the single-minded task of educating and negotiating with the television industry, whose
leaders on many occasions have shown their willingness to cooperate.


     Health Services

     As already pointed out, the mental health services for children in the Region are limited or
nonexistent.  In the few instances in which resources have been allocated for the care of children they
are almost always used to provide direct services to individuals and only in exceptional cases are aimed
at particular population segments. 

     The care pyramid in the field of mental health is inverted:  its broad base corresponds to highly
specialized tertiary care that essentially serves the adult population and consumes most of the resources. 
The intermediate portion of the pyramid corresponds to psychiatric services in general hospitals and
mental health units of limited quantity and coverage in the health centers.  The vertex corresponds to
a few feeble endeavors to provide community services and some very limited attempts to provide care
at the primary level.

     Some specialists are inclined to favor the development of vertical and centralized programs,
which perpetuate the situation described above.  In the opinion of the Group, it would be wiser to
promote the creation of horizontal programs centered on the community and incorporated into the
traditional health programs that serve the communities.

     In this connection, mental health actions can gradually be integrated into the health teams at the
primary and secondary care levels and carried out by nonspecialized health workers.  The function of
the specialist will be to provide continuing education for these workers and to provide advisory services
for the identification and management of problems.  Disorders such as enuresis, hyperactivity, and
convulsive attacks are demonstrative examples of problems that can be solved at the primary and
secondary levels.  Situations will arrive, of course, that surpass the capabilities developed in the health
workers at those levels.  As a result, it will be necessary to establish effective mechanisms for the
referral of patients to specialists and for feedback to the originating entity. 

     Of great importance in this system, which attempts to strengthen the services in the communities,
is the promotion of social support networks.  These are, in fact, the first point of contact between the
population and the health services and education systems.  By promoting them and providing them with
technical support, the services will be able to establish an early warning system to monitor and solve
some of the population's psychosocial problems, in addition to providing care when it is needed. 

     There are numerous examples of maternal and child mental health activities that may be carried
out in the general health care facilities.  For example, prenatal care provides a unique opportunity for
promoting the establishment of early ties between mothers and children; the training of hospital
personnel and workers in health centers can assist in reducing the traumatic effects these institutions
may have on mothers and children; and the family planning clinics can develop activities relating to
family counseling, management of the home economy, analysis of problems, and the improvement of
family communication.

     In general, the relationship of patients and family members with the health care providers can
provide an exceptional opportunity to strengthen the roles of individuals, foster contact with reality, and
promote communication--all of which are elements of great value in the promotion of mental health. 
In order to achieve these relationships, the training of health professionals must be restructured, both
at the academic level and in the services.  Such changes are necessary not only with regard to general
health personnel but also to specialists.


     Research

     Research is a fundamental strategy for the development of services to promote the mental health
of children.  Each country must determine the areas in which special importance will be given to
research and appropriate priorities will be established.  In any case, there was consensus regarding the
desirability of promoting applied research that will be focused on the solution of the most urgent
problems in every country.

     An area of research that is of common interest to all the countries is epidemiological research
on population groups, either of the limited, cross-sectional type or of the longitudinal type.  It was
noted, however, that the latter, in spite of its evident merits, is problematic by virtue of the absence of
a service structure that facilitates data collection and processing over a period of several years and of
the varied and costly resources that would be required to supplant this absence. 


     There was agreement on the need to systematize, register, and disseminate information on
various aspects of the mental health of children.  As the programs are expanded, monitoring of the
population strengthened, and the activities evaluated, exchanges in this area will become more feasible.

     The capacity of the countries to carry out research on the mental health of children is limited by
the lack of human resources, technical capability, and material inputs.  In this regard, the appropriate
international organizations should act as medi