Breaking Stigma and Building Support: Dr. Himani Adarsh’s Vision for Child Mental Health (Part - 3)

Dr. Himani: As I have discussed earlier also, family members play a crucial role in management. There are well-established modules for a complete family assessment, which I use in my clinical practice. Also, if needed you can liaise with a psychiatric social worker for a detailed family assessment. After which depending on the issues identified, we plan family interventions. The goal is to improve communication, solve family problems, understand and handle special family situations, and create a better-functioning home environment.

Working with families involves education, and teaching coping skills to families of patients with different psychiatric disorders. Various interventions exist for different disorders such as depression, psychoses, and substance use disorders. I start with providing psychoeducation, which involves giving basic information about the illness, its course, causes, treatment, and prognosis. After a thorough assessment of the family's needs and problems, structured family therapy is started.

Dr. Himani: Individualized Education Programs (IEPs) and 504 plans are both designed to support students with disabilities. But they work in different ways. IEPs include details of special education services and support a school will provide to meet the unique needs of a student with a disability. It includes specially designed instruction. IEP is based on the individual student's needs, taking into account the student's preferences and interests. In India, there are some associations, like the Dyslexia Association of India which is a charitable trust that addresses the needs of children who have this specific learning difficulty and any related co-morbidity.

504 includes a formal plan for how a school will remove barriers so a student with a disability can learn alongside peers in general education. Parents and guardians of students with disabilities or special health care needs are important members of their child's education team. They should work with educators to develop a plan that helps kids succeed in school. Every effort is made to help kids learn alongside their peers who do not have disabilities. But sometimes the level of support needed can't be met in a general classroom, so students are educated in a specialized learning classroom that is more appropriate for their needs. These classes have fewer students per teacher and allow for more one-on-one instruction. The teacher usually has training in helping kids with special educational needs. 

In India, The Rights of Persons with Disabilities (RPwD) Act, 2016 is a law that protects the rights of people with disabilities in India. RPwD includes 21 disabilities like Intellectual disability, Autism spectrum disorders, and Specific learning disabilities. Additional benefits such as reservation in higher education (not less than 5%), government jobs (not less than 4 %), reservation in the allocation of land, poverty alleviation schemes (5% allotment), etc., have been provided for persons with benchmark disabilities (i.e, more than 40%) and those with high support needs. Also, parents can visit the Unique Disability ID (UDID) site by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice & Empowerment to get further information and apply for a UDID Card & Disability Certificate.

Dr. Himani: Over the years researchers have started to realize that children and adolescents have different needs compared to adults and work on advancement in this field is ongoing. But till now there is a dearth of good evidence-based studies related to various psychiatric disorders as well as medications. This is due to various ethical issues, which I am not discussing in this article.

Many domains related to phenomenology (i.e., symptoms of a psychiatric disorder) are still not available in literature specifically for children, and the criteria used for diagnosing some disorders are validated only in adult populations. A lot of work is going on abroad as well and child psychiatrists in India are also working on developing diagnostic algorithms, particularly for pediatric patients. There will be more advancements in this field in the years to come.

Dr. Himani: When it comes to dealing with any issues with children, the one theme that is common for almost all parents is that they become anxious and overprotective seeing their child suffer. This is a very common reaction being a parent and it is completely normal based on the situation. Particularly when it comes to them that their child might have a mental illness, they feel a range of emotions and can make up some irrational decisions which can further damage the mental health of their child.

There is a fear of judgment and being labeled by relatives/society. Due to this, they don’t bring the child to the mental health professionals. Instead, initially try some faith healing rituals, or some other forms of treatment. Also, prefer to go to some random counselors, who are not even qualified enough to treat mental disorders in children. Sometimes patients come to us at a very late stage, and it becomes difficult to achieve full recovery.

A few families are antagonistic toward mental health services as they worry about labeling if their children are seen by mental health professionals. I understand that it's very difficult for a parent to accept that your child is suffering from some mental health issue but remember if the problem is diagnosed early and an adequate treatment is given, the child will recover well.

Dr. Himani: To start, the most important aspect is educating teachers and students about gender identity, and sexuality. These topics can be taught age-appropriately and in a way that children can understand. Support from school personnel – including school administrators, educators, and staff are critical for promoting the safety and well-being of LGBTQ+ students.

Addressing bullying and harassment is a crucial step to support LGBTQ+ students. Student-led clubs involving students and advisors that operate like other student extracurricular clubs should be made. LGBTQ+ related resources providing information and support services should be included in libraries, schools’ websites, or posters on walls in classrooms.

In India, there is a lack of trained teachers/staff who can deliver lectures on these topics. The education system and policies need to improve to create safe learning and teaching spaces in schools for teachers, parents, and students.

Dr. Himani: As a therapist, it is important to be emotionally available to the client in order to treat mental health disorders. Prioritizing self-care and stress management is essential for sustaining mental health and effectiveness as a psychiatrist. The key principle is to set definite boundaries, by establishing clear limits on work hours and patient load. I usually prefer to keep my sundays free and spend time with my family.

Maintaining a healthy diet, regular exercise, and practicing mindfulness skills have worked well for me. Anyone can schedule time for their hobbies based on their interests and availability. While doing psychotherapy if there is a challenging situation, I prefer discussing it with my seniors and seeking help whenever needed.

Dr. Himani: Schools can employ school counselors, social workers, or psychologists to address mental health needs promptly. The National Education Policy (NEP) 2020 in India recognizes the importance of school counselors in the educational system. NEP has recommended that the counselors be hired at the school complex level and their interaction not just be limited to students, but also be extended to parents, teachers, tutors, and other community members.

Regular training sessions for school staff should be done so that they can early identify behavioral, emotional, and academic issues in their classroom and guide referral to a professional. There is a need to build relationships with local mental health organizations to provide accessible services within or near the school. School authorities should arrange lectures by mental health experts within the school campus and encourage parents to attend the same.

In India, till now there is no universal school mental health programme. The most important step is to develop a school culture in which teachers and other student support staff are trained to recognize the early warning signs of mental health issues in students. A referral process should be developed to ensure that all students have equal access to mental health services and support.

Dr. Himani: Liaison with other health professionals becomes essential when we are dealing with pediatric cases. As a mental health professional whenever a case comes to me, I aim to provide a holistic treatment. To achieve this goal, a thorough assessment of what comorbidities are there (both psychological and medical) needs to be done. After that you can decide on liaison with other experts, for IQ testing you can collaborate with a clinical psychologist, if there are medical issues you refer to a pediatrician, for family-related issues you can utilize the expertise of social workers and so on. To me, a close liaison and follow-up of clients has always proved to be beneficial in achieving my treatment goals.

Dr. Himani: The first step in enhancing mental health in schools is to establish a proactive, inclusive, and encouraging school culture. Creating awareness about mental health is of utmost importance, it will lead to better understanding and reduction of stigma. I recommend incorporating mental health education into the curriculum at various class levels and allowing the students to talk about it freely, without judging them. When some student asks for help, they should be rewarded and encouraged, rather than telling them that they are making excuses or avoiding studies.

Most importantly, sensitization of teachers should be done regularly so that they can understand the mental health needs of their classroom and advise referrals to mental health professionals at the right time.

Dr. Himani: For me, this field is full of exciting cases, thoughtful conversations, emerging therapeutic techniques, and a constant source of gratification with the work I do. Also, it's an emerging super specialty, and there is a lot of scope to develop further both in terms of clinical expertise as well as in research. Generations have changed, and we are moving from Gen Z to Gen Alpha and now Gen Beta. We as adults need to understand our youngsters and provide them with a safe environment and proper guidance for their issues.

Medical professionals who are interested in mental health can contribute a lot to our future. Those who choose to do an M.D. in psychiatry can decide about their interest in this super-specialty. In India, currently, only 2 institutions are running the D.M. CAP courses (PGIMER, Chandigarh, and NIMHANS, Bangalore). In some colleges, a 1-year fellowship course is available in child and adolescent psychiatry. Those who have completed a master’s degree in clinical psychology or a related field can further pursue specialization in child psychology and development. Currently, there is a serious shortage of qualified child and adolescent psychiatrists, and child psychologists in India.