Empowering Families in the Management of Childhood and Adolescent Psychiatric Problems using a Public Mental Health Paradigm

This is the authors' abstract. We don't add key points for this paper.

India is one of the largest populations of children and adolescents in the world. Hence, to achieve Sustainable Developmental Goals, focusing on the health-care needs of children and adolescents' becomes an essential mandate. Since mental health is a prerequisite to healthy growth and development, one needs to be cognizant of the available options to fill the gaps. Mental health of children is of significant concern as nearly 20% of children globally suffer from one or the other mental health problems. In an estimate from 36 countries, approximately 250 million children in the world are likely to be suffering from mental health issues at any given time.[1] In India, a recent meta-analysis reported that 6.5% of children and adolescents from the community and 23.3% from schools have psychiatric disorders.[2] In addition, most of the adulthood mental health problems have some precursors in childhood, particularly up to the age of 14 years.[3] Thus, there is an urgent and imperative need to consider childhood mental disorders as a public mental health issue in terms of prevention, early identification, and reducing the treatment gap. In India, the treatment of mental health issues of children and adolescents is akin to having an “elephant in the room.” In general, the treatment gap for mental health disorders has been reported to be as high as 90%.[4] Majority of the children with mental health difficulties are unable to seek help. The children are unlikely to seek help independently and the decision-making process would involve family and related factors. The involvement of parents at each step would certainly facilitate help-seeking for the mental health-care needs of children and adolescents. Simplistically defined, a family typically consists of at least parents and children living together. Although families in the Indian context have disintegrated from joint to nuclear or even single-parent type over the years, family remains the primary caregiver for the young. The knowledge of impact of the interplay of the complex Indian family system on mental health-care needs and help-seeking would certainly give an in-depth insight into the processes involved in treatment initiation and maintenance. It was in the late 1950s that Dr. Vidya Sagar from Rohtak successfully demonstrated good recovery, reduction in stigma, and acceptance of the mentally ill in the community by involving families in treatment planning and delivering care. However, his concepts, for reasons not understood, are still awaiting appropriate implementation. The role of family environment in the development of psychopathology has been of much interest; especially regarding the interaction between nurture–nature context. A healthy nurturing environment undisputedly ensures healthy development of the young mind. However, several factors such as parents' knowledge, experiences, their own mental illness, and deprivation may compromise not only their parenting but also their child's mental health (and related needs) which can serve as barriers to help-seeking. In scenarios where training and trained workforce are limited and at places even inaccessible, it would be profitable to strategize simple yet effective public health approaches for enabling an emotionally stable family environment. This would go a long way toward promoting positive mental health and reducing mental and behavioral issues at all economic levels. A positive family environment as an over-arching framework can make a child resilient to all intra- and interconflicting situations with peers, schools, and society. Concepts such as quality time, shared family meals, open communication, consistency in disciplining, and usage of positive reinforcements are some of the guiding principles for creating a nurturing family environment. This would strengthen protective factors, thereby reducing vulnerability to mental illnesses and help the child to bloom fully. However, giving “quality time” to the children may be as alien a concept to a parent belonging to lower strata as it may be to that from an educated bureaucratic family. The rationale may be different; a parent of low socioeconomic status (SES) might not understand the need to sit and converse apart from making sure that the food is available to another extreme where another parent (high SES) may not be available due to preoccupation with their daily mundane activities. From the perspective of the affected child, either rationale has one end result, i.e., nonfulfillment of his/her emotional needs. Application of ecological model in public health approach for child mental health demands expertise at all levels involving health professionals (including mental health professionals) to community and family. Efforts through different programs such as district mental health program (DMHP) have been ongoing yet there has been a lack of focus on the various needs and mental health issues related to children and adolescents. This may be due to either lack of emphasis or expertise (or both) required in dealing with their mental health needs. It is important to consider investing in planning innovative preventive strategies besides focusing on empowering families with the skills to share the burden of clinicians in early diagnosis, initiating help-seeking, and assisting in intervention and long-term follow-up. Families may be a pivotal point for undertaking any action for both prevention and intervention. This would need addressing the barriers toward good parenting, as well as enhancing understanding of common mental health disorders occurring in childhood. Thus, a two-pronged approach: general strategies along with specific skills may be required to enhance effectivity of efforts. Families may be empowered, through multiple ways, using multimodal systems. However, the most basic yet most important method is psychoeducation. Awareness and understanding about childhood disorders and the relationship between familial factors (parental conflict, family time, neglect, abuse, perceived emotional, and economic deprivation) and mental health of children may enhance a positive environment as well as reduce barriers to help-seeking. Reaching the masses is now easy with the use of technology (TELEMANAS and mobile applications). Indeed, public health services are much more accessible with technology than before. In fact, making interactive mobile applications (like Arogya Setu) would probably be much more convenient to parents for collecting information, providing general parenting skills, and help for the behavioral problems of their child. Hence, using apps or developing videos that can be assessed on mobiles can be an easy and effective way of assisting parents to identify most of the childhood disorders. However, a recent systematic review[5] on the impact of digital health interventions on parental outcomes, including help-seeking, reported only low-quality evidence. More research is required in this area before we can upscale the digital literacy campaign. For problems such as autism and intellectual disability, parents are seen to indulge in doctor shopping from physicians to pediatricians to temples in the hope of cure for the illness. Thus, families need to be involved and educated not only for enhancing mental health care for their children but also to find support in decreasing their own stress levels. Parents have to face varying behavioral and mental health challenges occurring due to externalizing and internalizing conditions. Attention-deficit hyperactivity disorder, while overlapping to some extent with these behaviors, manifests more distinctly due to overactivity, inattention, and impulsivity. Children with special needs usually need care for their developmental disabilities. Based on these distinct needs, evidence-based individual and group intervention programs (like Triple P, Incredible years)[6,7] have emerged for different conditions and age groups in western countries. Such public health approaches directly target parents and families to reduce behavioral issues and improve communication and relationships. In India, these approaches have been largely used for dealing with neurodevelopmental disorders, i.e., autism and intellectual disability. Home-based interventions have largely been documented in the West and only a few Indian studies[8] have attempted to develop and examine their feasibility. Group model has also been used with families of children with neurodevelopmental disorders. It does provide an opportunity for parents to learn from other parents and also serves as a social support group. It facilitates in developing skills for dealing with behavioral and communication issues. Group approach may be a more viable option in India where trained mental health resources are not only few but limited to urban centers. Despite recognizing the need for scaling up of family involvement, systematic and continuous planning has been lacking to reach out to parents, especially those of the vulnerable population. Thus, the foremost focus needs to be on strategizing ways of reaching out to families. Schools may be conceptualized as one such link between professionals and families, thereby one can use them as a conduit to empower families for imparting psychoeducation and skills. So far, schools have been predominantly perceived as educational centers for children. A change in mindset and with more systematic planning and long-term vision may open a new vista for training families in the “public” than the “hospital” setup. By this approach and conceptualization, developing a public health model for childhood mental health that takes a community-based approach for promotion, prevention, screening for early identification, and empowering families with skills to deal with behavioral and emotional issues may be the potentially ultimate solution that mental health professionals have been searching for! However, it is a “Road less Travelled….”!