arents of a thirteen-year-old girl brought her for consultation recently, following episodes of repeated self-harm. She had become noticeably withdrawn from both family and friends in the past several months. She was moody and had become pessimistic in her outlook toward life. She had also developed a short fuse; got irritable often; and talked of feeling worthless. She had stopped engaging in activities she once enjoyed. Alongside difficulties at school, there was a significant negative change in her mood and thinking. Her family reported that that she had less interest in her physical appearance. These difficulties worsened over a month with repeated self-harm episodes. These were related to parental conflicts and her academic/ social difficulties at school. This presentation is only one of the steadily increasing number of children presented with mental health difficulties in recent years.
Children are the most important asset of a nation. Physically and mentally, healthy children make a healthy nation. All children have rights, just as adults do, whatever their age. These rights include rights to equality, health, education, a safe place to live and protection from all kinds of harm and a nurturing environment which is conducive to their physical and mental well-being. Through the United Nations Convention on the Rights of the Child, these rights are universally applicable to children living in various cultures and societies. Despite progress in recent years in many areas related to physical health, like eradication of infectious diseases, improvement in nutrition status, enrolment in schools, the focus on mental health interventions remains lacking, sadly.
Mental health in children and young people remains a pressing global public mental health priority. The World Health Organisation (WHO) estimates that approximately 20 percent of children and adolescents suffer from psychiatric problems. Almost 50 percent of adult psychiatric illnesses have their onset in childhood. Onset of major depressive disorder is often in adolescence, with suicide being the third leading reason of death among adolescents. In low- and middle-income countries like Pakistan, the risk of mental health problems in children and adolescents is further elevated as they face a horde of hardships including rapid unplanned urbanisation, poverty, malnutrition, lack of education, substance misuse, high rates of crime and violence etc. Furthermore, the Covid-19 pandemic and the recent devastating floods have brought a parallel pandemic of psychosocial problems, especially for children and adolescents.
Child and adolescent mental health problems manifest themselves in many domains and in various ways. It is important to recognise that some signs of distress are not obvious. Young children may display their worries in ways that caregivers may interpret as misbehaviour, oppositional/ defiant behaviour and temper tantrum. Parents may notice that their toddlers and pre-schoolers are more fussing, struggling to focus or engage in play and are becoming more aggressive. Some children may start showing typical regressive behaviours like asking for bottle, thumb sucking, bedwetting as well as problem in sleeping. Older children may present with aggression, restlessness, irritability, anxiety, low mood, physical symptoms, changes in sleeping or eating patterns and deterioration in social and educational functioning. It is of extreme concern that a majority of children having mental health difficulties that need services have limited access to mental healthcare because of widespread stigma. It is not uncommon in our culture for parents to be blamed for a child’s mental illness or it being attributed to spiritual causes and possession by devil. Stigma faced by children and families includes but is not limited to, bias, stereotyping, embarrassment, rejection, fear, basic human rights violation and denial of learning and training opportunities.
Addressing mental health distress in children is important because of their vulnerability and higher risk of long-lasting negative impact. Costs for societies are very high for child mental health problems, as both children and families are affected. Children lose out on school and productivity and families often have to stay at home to manage children with difficulties. Evidence suggests that poor mental health in early years is linked with academic difficulties, delinquency, interpersonal problems, substance abuse besides increasing morbidity and mortality throughout the life course. The WHO highlights that “lack of attention to the mental health of children and adolescents may lead to mental disorders with lifelong consequences, undermines compliance with health regimens and reduces the capacity of societies to be safe and productive”. Despite the widespread recognition of child and adolescent mental health problems in Pakistan, less than 1 percent of the health budget is allocated to mental health and none specifically for child mental health.
There is recognition that there remains a wide gap between what is urgently needed to decrease the burden of child and adolescent mental health problems and available services and resources in this field. To address huge challenges in provision of services, the public health approach incorporating promotion, prevention and treatment is the need of the day. All stakeholders need to focus on augmenting positive mental health for all children and adolescents, irrespective of whether they suffer from mental health problems or not. Parents can play a huge role in supporting their child’s mental well-being. Nurturing and loving care and positive parenting strategies build a strong foundation, helping children to develop the social and emotional skills needed to lead a happy, healthy and fulfilled life. There needs to be a focus on modifying the social determinants of health and improving the community’s capability to optimise mental health by focusing on nutrition, physical health, parental mental health, child friendly spaces and extra-curricular activities, to name a few.
Awareness campaigns for policymakers, communities and media aiming to improve child mental health are essential. Schools can play a critical role in promoting resilience and protecting mental health by emphasising development of coping skills, encouraging relationships with friends and teachers and providing a safe and nurturing environment for learning and community participation. Highlighting child mental health in every community forum, media and schools will decrease stigma and discrimination and improve the understanding of mental health problems within families and the wider community.
Although child and adolescent mental health promotion is a global challenge, it is potentially rewarding. Hopefully, focusing on child mental health as a priority in Pakistan will lead to not only healthy and happy children and adolescents but also a productive and stable society.
The writer is the head of the Department of Child and Family Psychiatry, King Edward Medical University/ Mayo Hospital, Lahore