Mental illness and its fallout were recently the focus of the 15th Annual Academic Sessions organised by the Sri Lanka College of Psychiatry. Along with unravelling little known aspects of mental ill health the discussions also turned their lens on the media and its role in reporting on mental illness.
Going on the recent WHO revelations that 10-20% of children and adolescents experience mental disorders and half of all mental diseases begin at the age of 14, the Sunday Observer spoke to Consultant Child and Adolescent Psychiatrist Lady Ridgeway Hospital, and Senior Lecturer Faculty of Medicine, University of Colombo, Dr. Sudharshi Seneviratne .
Here she shares her insights drawn from her hands on experience of over three decades.
Excerpts…
Q. The 15th Annual Academic Sessions held recently, organised by the Sri Lanka College of Psychiatry revealed little known aspects of mental ill health and mental disease . As a panelist speaker I understand, you too shared your views with a focus mainly on mental illness in children and adolescents. While mental illness and mental disease in adults has been clearly defined by the Diagnostic and Statistical Manual published by the American Psychiatric Association, does this apply to children as well?
A. If I were to reply on a broad term I would say, yes. There is a special section on mental and behavioural disorders during childhood in the same DSM V. We also use the ICD -10 which is the UK equivalent for the diagnostic criteria. But, when it comes to disorders which are present both in children and adults such as depression, we do not have a specified criteria for children. We are governed mainly by the adult criteria. On the other hand, there is another classification which is called the 0-3 classification. This is a USA classification.
Q. What kind of mental illnesses do young children suffer from, usually?
A. There are a whole range of mental and behavioural disorders, which we can broadly divide into three groups:
1. Behavioural disorders- attention deficit disorder, conduct disorder
2. Emotional disorders- depression, phobias
3. Developmental disorders, autism, dyslexia
Q. What causes them in young children?
A. The aetiology is varied. Some are due to genetic causes e.g fragile x-syndrome is a genetic disorder with hyperactivity and learning difficulties. On the other hand, some have a clear relationship with social problems. The best example is Conduct Disorder. Most of them have multiple causes which are both genetic and environmental. For many, the direct cause is not identified.
Q. Are they treatable if detected early?
A. It depends on the condition. Some conditions like phobias and depression can be treated successfully. On the other hand conditions like autism need long term input for improvement, but they might continue to have symptoms even as an adult. Some conditions like learning difficulties will not need medical treatment but most would require behavioural and cognitive input.
Q. Do they require drugs like for adults or can they be treated with less rigorous treatment. Or behavioural therapy?
A. It depends on the diagnosis. If we diagnose a condition we try to manage with behavioural interventions as much as possible. This is according to guidelines. But, there are conditions like childhood schizophrenia or severe depressive disorder where the first treatment option will be with pharmacological treatment. The treatment is planned case based, and the best option or a combination of options will be used.
Q. If they do start using medications when will that happen? Are these medications additive?
A. The medications will commence once a diagnosis is made. Prior to starting medication the necessary investigations will be done and after starting we monitor for response and side effects. These medications are not additive. Many hold the belief that they will not be able to go out of the medication.
This is not correct. We need to use medication only if there is an indication and we will stop once they are better. Some medications might need to be used for a longer term.
Q. The WHO in its report says, worldwide 10-20% of children and adolescents experience mental disorders and half of all mental diseases begin at the age of 14 and three fourths by mid 20s. Your comments?
A. Yes, most mental illnesses begin during adolescence. The main disorders are depression, bi-polar illness and schizophrenia.
Substance use disorders also start at this age, but somewhat later in Sri Lanka. Some developmental disorders and attachment disorders start much earlier. The developmental disorders are from birth.
Q. At what age is a parent able to detect the first sign of a mental illness in a young child?
A. It differs according to the illness.
Q. Gender wise, are children of both sexes equally vulnerable or does one gender predominate the other? If so why?
A. There is a predominance of males affected by most of the childhood mental illnesses. The cause is not known.
Q. Can one inherit a mental illness?
A. Yes. However, the environment needs to be correct for some genes to express themselves. So, while some may develop a mental condition, others may not.
Q. What are the health impacts of mental illness in children?
A. There are many impacts on a child and his family. The behaviour of the child may be a challenge and would need input. Also, we need to consider areas such as speech, communication , mobility and even education. All of these areas have a direct effect. Other than these areas there can be problems with peer interactions, family interactions which can affect their day to day lives.
Q. Are they lasting? Can they be reversed?
A. It is variable. A child who has a mild impact, with good resilience and support can overcome some of these problems. Children who do not have support or who continue to experience further adverse effects will have long term consequences.
Q. Stigma. It has been said that effective treatment of a mental illness is often impeded due to stigma and the reluctance of parents to acknowledge that their child has a mental condition . This could result in them seeking therapies with non psychiatrists hoping for relief, which is dangerous. Do you agree with special reference to a school going child?
A. Yes. We see many parents who are reluctant to accept a diagnosis and wish to seek help from other agencies. There is also a delay in presentation because of the stigma.
Q. Can stigma undermine a child’s self esteem? Can it also spill into the classroom, the school van, play ground?
A. Yes. We have seen many children who have been excluded from activities due to their illness. Teachers, school staff and peers bully them without understanding the reason for their behaviour. We have seen some children severely affected by stigma which has worsened their own illness.
Q. Can it affect the child’s ability to concentrate?
A. Once a child is a victim of stigma he can react in different ways. He/she can either externalise the problem with aggression or they can internalise the problem as depression or anxiety.
Q. Does a hyperactive child fall into the category of a child with a mental illness?
A. Mere hyperactivity is not an illness. A definitive diagnosis of hyperactive disorder has to be made prior to labelling a child.
Q. As a specialist in adolescent health as well, do you agree adolescents are also vulnerable to mental ill heath?
A. Yes. Adolescence is a very vulnerable period as they are open to all sorts of influences and are impulsive.
Q. Who is best qualified to make an accurate diagnosis? A Psychiatrist? Psychologist? General Practitioner?
A. A medical doctor can make a diagnosis based on the criteria we discussed earlier. It is best to have an opinion by a Psychiatrist so the best treatment options can be explored.
Q. When a child/ young person is brought for examination to your clinic, what is the usual procedure?
A. We do a thorough study of the history of each case taking into account the parents, teachers and others closely connected with the child. We also observe the child in his or her setting. There are some assessments we carry out on paper with the child’s involvement. If required further investigations will also be carried out.
Q. Sometimes, young people suffer from fears which superstitious parents believe are the work of the devil and they hold thovils etc to cast them out of the victims who become worse. Your comments?
A. We see this often in our practice. It is a superstition held by parents. There is no clear truth in it. At times parents’ beliefs overflow to the children and they are also caught up in these thoughts. It is very difficult to address them at times.
Q. Your recent discussion was on the theme of “Psychiatry & The Media Towards better communication”. Tell us what you think on the role of the media, especially, when reporting news on mental illness in children and adolescents?
A. I think it is very important that the public is aware of the concept of mental illness. It is a difficult area to report on, as many are unaware of the technical terms used in different presentations. Just because a child has an abnormal behaviour does not qualify him to be diagnosed as having a mental illness. Unfortunately, some media personnel come to their own conclusions and highlight only the mental illness aspect. It is very important to clarify facts prior to reporting. If there is a doubt it is best to get an opinion from a psychiatrist and then report on this.
Q. Do you see any gaps in the present delivery of services in the area of mental illness in children and adolescents?
A. We have many areas that need to be improved. The services are not well distributed around the country as we have only very few trained child psychiatrists.
To overcome this, all adult psychiatrists also see children and adolescents. Specialised behaviour therapies take much time to be delivered to patients. So, the consultation time to see a child will be longer. In addition, we have only a limited number of psychologists, speech therapists and occupation therapists. It is important that these children are seen by a multidisciplinary team.
Q. Have you a word of advice to share with parents ?
A. If there are concerns about your child it is best to seek the opinion of an expert without delay.