Development of Child and Adolescent Mental Health in India: The Last 40 Years

L. P. Shah, MD, FIPS, FAPA (USA), FRC. PSYCH. (UK)
President, Indian Association of Child and Adolescent Mental Health

Renu B. Sheth, MBBS, DPM
Consultant Psychiatrist

In India, the earliest document to record child development was Ayurveda. The study of child psychopathology was considered as a downward extrapolation of psychopathology of adults. Thus, the growth of child psychiatry in India has occurred following the growth of adult psychiatric services. Though in the Western world, child mental health services were started about eight decades ago, In India, its origins can be traced back to only about four decades. This is probably because psychiatry was introduced in India by the former colonial powers having a different cultural background and language than that followed by the Indians. There were no opportunities of mental health care for children, as their development rested with the local socio-cultural milieu. It was only when native psychiatrists emerged and were able to understand the existing conditions as a result of communication with the local population that they began some services for the children.

Existing Training Facilities

Undergraduate Level

At an undergraduate level, students have to undergo a fifteen day clinical term in Psychiatry during which hardly or no emphasis whatsoever is given to child and adolescent psychiatry. Besides, in the final year examinations since there is just one short note on a topic in Psychiatry and at some places since this too is optional, there is practically no awareness about child mental health at an undergraduate level. The training for students is also limited to one or two weeks only in Psychiatry during which they get almost no exposure to child psychiatry cases.

Postgraduate Level

At a postgraduate level, Child Mental Health is included in the training program for students training in the fields of MD Psychiatry or Diploma in Psychological Medicine, MD Pediatrics or Diploma in Child Health, and Preventive and Social Medicine. In Psychiatry there is a lack of skilled training personnel and in the other fields there is no mandatory training as such in child psychiatry, hence even at a postgraduate level, students do not have much experience in identifying and dealing with mental disorders in children and adolescents.

Other

In India, few specialized courses are available in the areas of Child Psychiatry, Child Psychology and Social Work. There are limited facilities for training courses of paramedical personnel and community health workers. There are few training centers for teachers in the area of mental retardation and special learning disorders.

Existing Services for Treatment

There were only about 75 child guidance clinics in 1973 (Marfatia, 1973) which increased only marginally to about 120 child guidance clinics managed by general psychiatrists in 1989. Recently some genetic diagnostic centers, crisis intervention centers, centers for substance abusers and special schools and vocational training centers for mentally disabled children and adolescents have been set up, mainly in the urban areas of our country. These centers are managed by the general psychiatrists, pediatricians, clinical psychologists and psychiatric social workers and nurses. Special schools for the mentally retarded, mentally handicapped and gifted children are being run by special teachers trained or interested in handling these children. A lot of orphanages, correctional institutions and non-government organizations have been set up with the aim of helping such children and adolescents. As per Master in 1992, there is a lack of well qualified, trained staff in our country.

The number of specialized inpatient and outpatient facilities for children are very few and are mostly attached to Psychiatric and Pediatric departments of various medical colleges and other special institutions. These also differ in their structure, functioning, and in the available therapeutic facilities and are mainly situated in urban areas. There are practically no facilities available in the rural areas. That the services are still inadequate has been reported by workers from Africa (Hazera 1972; Izuora 1970, 1972; Asuni 1970) and Southeast Asia (Ramanujam 1968; Marfatia 1973; Rosheen Master 1988).

Training Facilities and Treatment

Services Required

Basic knowledge of child psychiatry should be incorporated at an undergraduate level, and during internship there should be compulsory exposure to child psychiatry cases.

At least six months training in child psychiatry should be made compulsory for students doing their postgraduate in Psychiatry so as to train them to be able to identify and treat the common mental disorders in children and adolescents. Similarly postgraduate students in the areas of Pediatrics and Preventive and Social Medicine should have mandatory training in Child Psychiatry for at least one month of their total tenure.

Adequate facilities should exist for training of clinical psychologists, social workers, occupational and speech therapists and psychiatric nurses to deal with Child Psychiatry cases.

School teachers and community health workers should be trained for early identification and prevention of psychiatric disorders in children and adolescents.

Many more special schools with trained personnel should be started for exceptional (gifted) children, mentally handicapped

children, and children with specific learning disorders.

Educational programs should be held to increase awareness in parents, teachers, as well as the local population regarding the proper development of children, and prevention, early identification and management of psychiatric disorders affecting children and adolescents.

Child Guidance Centers managed by skilled mental health professionals need to be set up in the urban as well as rural areas.

Research Studies

In India, hardly any studies have been done in the field of child and adolescent psychiatry. The ones that have been done concentrate mainly on the epidemiology and the use of assessment schedules. Very little research has been done in the areas of phenomenology, etiopathogenesis, treatment and adverse effects.

Epidemiology

Epidemiological studies at the community level were initiated about two decades ago. In a multicentric WHO sponsored study of childhood mental disorders in primary health care in four developing countries, Giel et al (1980) reported that 12 - 29% of children attending a primary health care facility in Columbia, India, Senegal and Sudan had identifiable psychiatric disorders of which 80-90% are consistently missed.

In the urban areas, studies by Sethi et al (1967), Verghese et al (1974) and Lal and Sethi (1977), revealed a prevalence rate of 9.4%, 8.2% and 17.2% respectively, whereas in the rural areas, studies by Sethi et al (1972) and Nandi et al (1975) revealed a prevalence rate of 8.09% and 2.5% respectively. Clinic based studies conducted on individual child psychiatric disorders have shown a wide variation in prevalence of behavior disorders, ranging from 3-36% (36% Bassa, 1962; 13% Chacko, 1964; 3.3% Murthy et al, 1974; 3% Praveen et al, 1988; 4.6% Singh and Gupta, 1970); and neurotic disorders ranging from 3.7%-54% (Chacko, 1964; Manchanda and Manchanda, 1978; Nagaraja, 1966; Praveen et al, 1988; Raju et al, 1969; Sharma et al, 1980). A study conducted on school children by Jiloha and Murthy (1981), reported a prevalence rate of psychiatric disorders in 20.7% children and the common disorders reported were enuresis (8.8%), mental retardation (5.9%), stammering (2.1%) and emotional problems (1.7%). Another study on school children conducted by Deivasigamani (1990) reported the prevalence of psychiatric disorders in 33.7% children, and the common disorders were enuresis (14.3%), conduct disorder (11.1%), mental retardation (2.9%) and hyperkinetic syndrome (1.7%).

The drug abuse surveys in school have identified alcohol and tobacco as the most commonly abused drugs in children (Varma et al, 1979). A recent study on drug abuse by Bansal and Banerjee (1993) in child laborers has revealed a higher prevalence (45%) than in school children, and tobacco smoking was found to be the commonest followed by tobacco chewing, snuffing, cannabis and opium. Studies have also been carried out investigating different variables linked to child abuse. For eg. Gil (197)) investigated social class and family size, Light (1973:556-98) investigated unemployment, and Garbarino (1977:721) investigated social isolation in child abuse.

Assessment Schedules

The main work pertaining to assessment schedules has been done in the field of assessment of intelligence. Only a few assessment schedules have been developed in the area of psychopathology. These are: Mental Health Item Sheet (MHIS, Verghese et al, 1973) for children up to 12 years of age, 16 items Symptom Checklist for Hyperactive Children (Chawla et al, 1981) and Schedule for measuring Temperament in children between 4-14 years of age (Malhotra et al, 1982; 1983a, 1983b, 1983c). Recently new assessment schedules have been developed: Psychiatric Symptom Screening Schedule (PSSS, ICMR, 1987) for children up to 16, Childhood Psycho-pathology Measurement Schedule (Malhotra et al, 1988), and Parental Handling Questionnaire (PHQ, Malhotra, 1990). As regards the mentally retarded children, there is a need to develop an assessment schedule which is not only limited to intellectual functioning, but which may also give an idea of the individual’s strength and weakness globally (Nizamie et al, 1989).

Phenomenology

In the last 10 years, various research studies have been carried out studying different variables linked to mentally retarded children. For example, Chaturvedi et al (1984), and Somasundram and Kumar (1984) studied behavioral characteristics; Thuppal and Narayan (1990) studied disabilities associated with mental retardation; Madhavan and Narayan (1992) studied epilepsy and mental retardation; and Tandon et al (1990) studies the orodental pattern of mentally retarded children. Some research studies have also been conducted in the area of time utilization and perceived burden of a mentally handicapped child (Wig et al, 1985) and multidisciplinary rehabilitation of the mentally retarded (Master, 1984).

The research work on manic depressive psychosis in children and adolescents is negligible. The symptomatology of juvenile manic depressive psychosis is reported to mimic that of adult manic depressive psychosis (Narsimha Rao et al, 1982; Srivastava et al, 1991). Patkar et al (1990) reported cases of prepubertal bipolar disorders with rapid cycles as are found in the adult population.

The phenomenology of schizophrenia was studied by Tandon et al (1991) and the symptomatology of hallucinations was studied by Tandon et al (1985). Some phenomenological studies have also been done on hallucinations in hysterical children and adolescents (Tandon and Sitholey 1987), temperamental characteristics of children with conduct and conversion disorders (Malhotra, 1989), autism in tuberous sclerosis (Khanna and Sood, 1991), specific development disorders in the children attending a child guidance clinic (Malhotra and Chhada, 1987) and somnambulism (Singh et al 1990).

Etiopathogenesis

Thuppal and Narayan (1990) studied etio-pathogenesis in patients of severe mental retardation and found the common etiological factors to be idiopathic, infection to the brain, birth anoxia, and trauma. Malhotra et al (1992) studied life events in children with psychiatric illness and found a positive correlation of live events with various child psychiatric disorders. The study of Chakraborty and Paik (1993) has revealed that interaction of many sociological factors may be related to an increased chance of developing delinquent behavior. It is obvious from the negligible amount of studies done on the subject that extensive research needs to be carried out in the area of etiopathogenesis of psychiatric disorders in children in India.

Pharmacotherapy and Adverse Effects

Various drug trials in children have revealed the efficacy of Hydroxazine (Manchanda et al 1969), Imipramine (Mahendru et al 1970), Phenytoin sodium (De Sousa et al 1989) and Mentat (Shah L. P. et al) in hyperkinesis and behavioral disorders. Narsimha Rao et al (1982) and Khandelwal et al (1984) have revealed the efficacy of Lithium as a therapeutic as well as a prophylactic agent for manic depressive psychosis in children. Singh and Mishra (1993) have stressed the role of Piracetam in dyslexia. Two prominent case reports have been published reporting the adverse effects on children and adolescents. One is related to bilateral frontal lobe CT scan abnormality following ECT in an adolescent (Janat and Banerjee 1992) and the other is related to Lithium neurotoxicity in an adolescent.

Future Trends

Designated centers at a state level to provide training and research facilities for all mental health professionals involved with children and adolescents, i.e., psychiatrists, psychologists, social workers, nurses, teachers, etc.

A need to develop an Apex center for training and research in child psychiatry.

A need to sensitize other professionals like general practitioners, probation officers, police personnel, etc., who are likely to deal with such children and adolescents. Short-term courses conducted on a weekly basis so that it does not impinge on their work schedule would also play a preventive role.

For adolescents in school, a need for school counseling programs which include vocational and career guidance, and at a community level, a need for youth guidance which includes guidance on family problems, sex, drug abuse, etc.

Conclusion

It is obvious that as yet, not much work has been done in the area of child and adolescent mental health, though there is a lot of potential for the future. The Indian Psychiatric Society established a Child Psychiatry section in 1987. On November 22, 1991, a separate association, the Indian Association for Child and Adolescent Mental Health, has been established with the purpose of promoting positive mental health in children and adolescents. It holds biennial conferences and is an affiliate of the Asian and International organizations.