Teens and trauma

Ranjani was 13 when her boyfriend left her. Depressed, the Jaipur teenager tried to hang herself. Timely intervention by her mother saved her life. The distraught girl took a break from school and started therapy sessions. Now based in Delhi, she feels she can cope with the world around her, Ranjani’s counsellor says.

Bengaluru student Ankita’s parent couldn’t understand why she didn’t want to attend school, despite getting good grades. The 11-year-old skipped meals and had angry outbursts. Her worried parents took her to a therapist. After several sessions, she told her counsellor that she was a victim of cyber bullying.

The two school students were fortunate to have parents who intervened. In a country where 15 people commit suicide every hour, and where the act of suicide is the top reason for death in the 15-29 age group, mental morbidity and depression in children and adolescents is an often overlooked area but a ticking time bomb.

Mental morbidity — physical and psychological deterioration — has many manifestations. These may include mood disorders, depression, post traumatic stress disorders, drug abuse, Attention-Deficit/Hyperactivity Disorder, anxiety and suicide attempts. Experts stress that while it can be triggered in childhood, it mostly manifests itself in children at the onset of adolescence.

Almost one out of five adolescents in India suffers from some level of mental morbidity, says a 2019 study conducted by the Bengaluru-based National Institute of Mental Health and Neuro Sciences. Male teenagers from urban, nuclear family backgrounds constituted the majority of its sample survey. They showed risk behaviour such as substance abuse, casual sex and speed driving and were found to be often in conflict with their family members and the law.

Reasons for incidence

Mental health professionals believe there are several reasons why mental morbidity is on the rise among adolescents. Some of the major factors are substance abuse, family conflict, relocation, peer pressure, peer-to-peer relationships and performance pressure in academics and other fields. Internet addiction is another problem that minors grapple with.

“Children get more overwhelmed now with disruptions in their life than they did earlier. Panic attacks have become very common in school children. There has been a rise in the number of cases related to body shaming as well. Children are increasingly involved in activities where they sit at home, instead of playing physically, or are involved in performance sports at all times,” says Chennai-based Parimal Pandit, programme director, counselling and assessment department, V-excel educational trust, a school for people with special needs.

Often parents’ work stress is transferred to their children. “Homes where rhythms are disturbed due to parents and their hectic lives can lead to lack of resilience in children, and can even lead to psychological disturbances. Anxiety, panic attacks, anger management issues, adjustment disorders, suicidal intentions and addictions are all behaviours that we see on the rise,” says Pandit. “Sleep patterns are often disturbed, leading to mental health disorders in children,” she adds.

Paranoid android: Sleep patterns and body rhythms are often disturbed in our modern way of life, leading to mental health disorders in children

Pandit stresses that puberty is anyway a vulnerable period, and usually leads to some disruption in an adolescent’s life. “However, if one’s home life and educational environment are balanced and supportive, there is no reason why puberty cannot be smooth sailing. Small crises are also necessary for children to develop resilience in life.”

To help children cope with some of the problems, they are encourage to “apply their energies creatively” in a positive direction, Pandit adds.

She points to the fact that children these days hardly get to play. Most activities typically involve competition leading to more stress. “Children need time to pause and take in the day’s learnings, with more activities such as painting or sports. Busy hands help in channelling emotions. The more one uses their hands creatively, the less the chance of self-harm,” says Pandit.

One of the roadblocks to effective treatment, however, is the parents’ reluctance to accept that their child may need professional help. And the law on mental health makes no mention of a meaningful role that a teacher or any other adult can play in dealing with childhood mental morbidity.

Policy measures

The Mental Healthcare Act (MHCA) was passed in 2017, three years after the National Mental Health Policy (NMHP). While the MHCA elaborates on provisions for the rights of mentally ill people, it gives little space to children and adolescents. All responsibility and authority when it comes to decision making for minors facing mental health issues have been placed in the hands of their guardians and care givers. In many countries such as the US, Britain and the Netherlands, adolescents, especially in the age group of 16-18 years, have the right to participate in decisions regarding their mental health.

The NMHP, an overarching document, lays out the guidelines for mental health programmes and provisions in the country. It put special emphasis on the mental health needs of vulnerable groups such as orphans with mental illnesses, children of adults with mental illnesses and children living in custody.

The MHCA, on the other hand, makes no mention of such children. It fulfils World Health Organization guidelines on issues such as limiting involuntary placement of minors in mental health facilities. But it does not deal with aspects such as the minimum conditions to be maintained for a safe, therapeutic and hygienic environment. The levels of professional skills required to determine a mental disorder are not specified and neither are categories of professionals who may assess individuals to determine a mental disorder.

Participation of minors

The MHCA places almost the entire responsibility for health-care decisions for minors on parents or guardians. In a country where mental health issues are taboo, this places patients at the mercy of their guardians. When a child turns 18, he or she gets all privileges available to a voluntary adult patient.

“This seems quite at odds with the understanding of adolescent development and the capacity of adolescents to appreciate their healthcare needs and take responsible decisions,” says Eesha Sharma from the department of adolescent psychiatry, Nimhans.

In many countries in the West, 16-18 year olds have legal rights to consent to or refuse treatment and/or inpatient admission. Parents/legal guardians cannot override their right. Adolescents can even make health-care decisions about their own medical treatment, without the need for parental permission or knowledge.

The consent of minors on all issues affecting them, including treatment, finds no mention in the MHCA act in India, in sharp contrast to laws in Western countries.

Need for standards

According to some estimates, India has less than one psychiatrist for every 100,000 people. To top it, there is no assessment of counsellors.

“The biggest problem in this area is that there are no standards set for practising counsellors in this country, and, by virtue of that, anyone can become one with minimal or no training,” says Chennai-based Vidya (she uses only one name) of the Tulir Centre for the Prevention and Healing of Child Sexual Abuse.

While educational institutions and others have been offering counselling services to students, there might be more harm than good in this direction, as none of these sessions is regulated, she warns.

Vidya adds that the problem affects all genders. “But boys who are abused are affected differently from girls, and suffer from the stigma attached to sexual abuse.” This may result in either unaccounted for aggression or depression, anxiety and other disorders that can manifest themselves later in life.

Sometimes, the affected children are as young as four or five. Sumit, whose parents are both employed in Chennai, was just five when they found him showing an obsessive interest in carrying out rescue operations with his toy helicopter. He had adjustment issues at school and began attending therapy which continued for a year. It was then that Sumit, who has a disturbed family background, told his counsellor he no longer felt threatened. This latent fear had pushed him towards games that revolved around rescue operations.

With the help of parents and counsellors, mental morbidity among children can effectively be handled. Parents, in particular, must be more aware of factors that lead to mental health disorders and provide a supportive environment to the young. “Mental health problems are nothing to be ashamed of,” a counsellor says.

The active participation from policy makers and stringent quality control on mental health support systems will lead to a healthier population, the experts stress. While currently India has the maximum number of depressed people in the world, timely intervention will help future generations.

(Some names have been changed to protect identities)