We often turn a blind eye to the mental health needs of children as it’s expected of them to ‘bounce back’ if they’re feeling low. However, with the pandemic, it’s now evident that more and more young children are not bouncing back from their lows and this is affecting other aspects of their lives. The effects can be severe enough to impact their day-to-day life and if these are not tackled promptly it is likely to continue into adulthood. Compounded by the fact that normal childhood development is subjected to behavioural changes from time to time it is sometimes difficult for parents to identify when their child is suffering from a mental illness. Therefore, to address the relative paucity of information on mental health issues in children, we spoke to University of Colombo (UoC) Faculty of Medicine Senior Lecturer in Psychiatry and Consultant Child and Adolescent Psychiatrist Dr. Dulangi Dahanayake MBBS, MD (Psychiatry).
What are the common psychological issues you encounter in children?
Psychological issues among children can be broadly divided into developmental, emotional, and behavioural disorders. In the Sri Lankan context, we see children presenting with difficulties in all of these areas, with some children having more than one condition. Common presentations are school-related issues such as school refusal, poor academic performance, aggression, excessive usage of electronic screens/internet gaming, oppositional behaviours, excessive fears, and persistent sadness.
These children are usually brought in by concerned parents. Sometimes schoolteachers also facilitate their referral.
Are there any triggers?
The school closure due to the Covid pandemic has been difficult for a lot of children. Lack of routine, online education/interruption of education, inability to meet friends, inability to engage in sports and other activities, above average access to electronic devices have all led to a rise in problems.
In addition, the triggers contributing to difficulties in children include issues at school and home. At home, domestic violence/parental conflicts are major contributing factors. Lack of a close attachment or relationship with parents leads to an increase in vulnerability for these problems. Parents provide for the physical needs, but due to multiple reasons, they are unable to be emotionally available for the children. Being emotionally available means being able to understand the child’s emotions, validating them, and helping children manage difficult emotions without brushing them aside or being overprotective. Lack of stimulation during the early years can also impact development.
The competitive nature of education and even extracurricular activities create stress for children. High-performing students are stressed out as they try to maintain their performance and the others are stressed out because their achievements are less than that of their peers. The parents also inadvertently contribute by announcing their child’s achievements or putting them on social media or putting pressure on children to perform better. A significant number of children present to us close to the grade five scholarship examination as well as O/L and A/L examinations. These are usually due to heightened anxiety and worries and we see both high-performing and underperforming children having these issues. Additionally, peer relationship difficulties are also a common trigger for such presentations, stated Dr. Dahanayake.
As shown above, environmental factors are extremely important in triggering emotional and behavioural issues in children. Due to increased dependence on the adults around them, children are more vulnerable to these effects.
What signs and symptoms should parents look out for?
Any change in the child’s behaviour needs to be looked into. Especially if they appear sad, are irritable, engage in self-harm, are socially withdrawn and/or there is a reduction in school performance. Frequent anger outbursts, sleep and appetite disturbances, physical complaints such as recurrent stomach aches and headaches without any underlying cause are important features to be vigilant for. In younger children, failure to achieve age-appropriate developmental milestones is also a reason for concern.
When should they see a doctor or a child psychiatrist?
- Changes in behaviour and emotions as above which impacts on relationships, studies, and other activities of the child
- Delay in achieving developmental milestones
Advice to parents regarding screen time and exam-related stress in the new normal
Screen time is a much debated issue, especially since the physical distancing measures including school closure adopted during the Covid pandemic. Due to online education, children have had increased access to screens. On the positive side, this has helped them to continue educational activities, maintain contact with family and friends, learn new skills related to using these devices and applications, and find leisure activities. However, there are increasing concerns about the negative impacts of excessive screen time on children’s physical and psychological health.
The recommendations for screen time are that it is best avoided in children below two years of age. In preschoolers and primary school children, screen time has to be supervised at all times. Parents should co-watch with the child and preferably discuss what they are watching. For older children, there should still be house rules and regulations regarding the time allowed with screens to make sure that this does not impact the child’s education, relationships, and other activities. Parents need to be in control of the situation while allowing the children to make age-appropriate choices regarding their screen time.
Examination stress has also increased due to the lack of physical schooling, lack of opportunity to engage in usual term tests and other assessments, and uncertainty regarding exam dates. The most important thing is to help your child develop a positive frame of mind, without feeling helpless in this situation. It is best to reframe the current circumstances as a challenge rather than a hopeless situation. In addition, emphasis needs to be placed on the process of learning rather than the outcome of the exam, because what we have control over is this process and it is what we can do in the present moment. Parents can also schedule some pleasurable activities for children to help them relax and enjoy time with others. Physical exercise, sleep, and adequate rest need attention as well.
What are the treatment options available for children?
Most of the time, parents are the ones who can facilitate a change in the behaviours of their children. Parent education and training of parenting skills are hence important aspects of the management plan. Children are also allowed to vent their feelings; their feelings are validated, and they are supported to come up with possible solutions for problems. Specific psychological and behavioural methods are also used. When needed, the school is contacted with parental permission and a support network is created for the child. Medications are used only for specific indications and in conjunction with behavioural and psychological therapies. The medications used are ones that have been tested and licensed for use in children, assured Dr. Dahanayake.
Take home message
Children need a lot of emotional support from their parents, teachers, and other caregivers around them. This should be balanced against providing them age-appropriate opportunities to explore their environment and learn skills related to problem-solving and decision making.
If there is a change in your child’s behaviour that is enduring and impacting on their functioning, do not hesitate to reach out for help. Your general practitioner, the out-patients department and the psychiatry unit in the nearest hospital are the best options available. In addition, the 1926 mental health helpline and chat line commenced by the National Institute of Mental Health is a suitable resource to obtain further information, concluded Dr. Dahanayake.