Child and youth mental health in postwar Sri Lanka

Abstract

Sri Lanka’s civil war and the tsunami in 2004 had enormous psychological impacts on the country’s children. Tackling these issues has been difficult due to the lack of specialists in child and adolescent psychiatry. The end of the war in 2009 opened new avenues for the development of mental health services for children and youth in Sri Lanka. The year 2016 was historic in that the first board-certified child and adolescent psychiatrists assumed services in the country, after training in Australia.

Sri Lanka is a South Asian nation with a multiethnic population of 21 million, consisting of Sinhalese, Tamils, Muslims and Burgers. It was estimated that there would be 7 million below the age of 20 years by mid-2016, which is a third of the total population.

The north-eastern parts of the country were ravaged by a civil conflict for 30 years, which ended in 2009. The whole country experienced frequent bomb blasts and more than 60 000 people lost their lives. In the war, a considerable proportion of militants were children, who were forcefully conscripted to fight as child soldiers. The whole range of psychiatric conditions were found among the children exposed to the war (Somasundaram, 2002). In a survey of children in north-eastern Sri Lanka, 92% stated that they had experienced severely traumatising events during the war, such as combat, shelling, bombing and witnessing the death of loved ones, and 25% had post-traumatic symptoms (Elbert et al, 2009).

Due to economic hardships in post-war Sri Lanka, one in ten Sri Lankans are employed overseas as international labour migrants, mainly as low-skilled labourers or housemaids. The remittances from them are the single highest contributor to the nation’s economy. Employment of females in the Middle East is a major problem, as two out of five of their children left behind are found to have mental disorders (Wickramage et al, 2015).

Mental healthcare in Sri Lanka

The mental health gap remains high and service development in remote areas has been hampered by a lack of qualified experts. In 2011 there were only 0.29 psychiatrists per 100 000 population. One of the reasons has been the brain drain, which has been a problem for many low- and middle-income nations (Oladeji & Gureje, 2016). The proportion of undergraduates stating a desire to take up psychiatry as a career pathway is about 2%, which seems to be low compared with that in many high-income countries (Kuruppuarachchi, 2008). However, the number of psychiatrists in the country has slowly risen since the end of the war.

A study in Sri Lanka demonstrated that young people were more likely than older people to use medicinal overdoses for self-harm following recent interpersonal conflicts (Rajapakse et al, 2016). Despite a reduction in overall suicide rates in Sri Lanka, young women continue to have higher rates than older women, whereas in high-income countries older women have higher rates than younger ones (Knipe et al, 2014).

Postgraduate psychiatric training

Doctors are trained for an MD in psychiatry by the Postgraduate Institute of Medicine in Sri Lanka. The 3-year training programme includes general adult, forensic, and child and adolescent psychiatry (CAP). After satisfactory completion of training, trainees are expected to sit for the MD Psychiatry Part Two Examination, attended by a foreign examiner, preferably from the UK or Australia. CAP has been recognised as a subspecialty and to become a child and adolescent psychiatrist (a board-certified specialist) a successful trainee at the MD Part Two Examination needs to complete a further 3 years of post-MD training at a local and a foreign CAP unit and to complete a dissertation. In 2016, for the first time, two board-certified specialists in CAP assumed duty in Sri Lanka after training in Australia. Even though there had previously been a few practising child psychiatrists, they were not board certified in CAP.

Child and youth mental health services

The Lady Ridgeway Hospital is a 900-bed tertiary-care children’s hospital in Colombo. The first in-patient child psychiatry unit was established in this hospital in 2002 and the second in 2014, with multidisciplinary care. An adolescent in-patient unit was opened recently at the National Institute of Mental Health, Colombo. The number of psychiatric beds for the whole country remains at 12 for children and a further 9 for adolescents. This is extremely low compared with figures in high-income countries.

Out of the nine provinces of the country, consultants provide solely specialised CAP care in only three: there are two such consultants in the Western Province, one in the Central and another in the Southern Province. Many children and adolescents with mental health issues are seen by general adult psychiatrists or are referred to the above centres when the need arises. At times, when treating certain child psychiatric conditions, pharmacotherapy, despite its sometimes serious adverse effects, is given prominence over psychotherapy (Chandradasa et al, 2014). Because in-patient facilities are concentrated around Colombo, clinicians tend to admit children of both genders to female psychiatric or acute paediatric units for assessment.

A major barrier in continuing care is the loss of follow-up of diagnosed children. Several factors have contributed to this, notably travel costs and the long distances to tertiary-care centres. This emphasises the need for community outreach services. All children at the ages of 6, 9 and 12 years are screened for medical problems at school and recent attempts have been made to detect behavioural and emotional problems in addition to the routinely screened physical health problems.

Abuse

A study conducted in the north of the island found that a majority of the allegedly abused were adolescent girls. Among the abused girls, 15% showed penetrative injury and in 70% of the cases the perpetrator was a person known to the victim (Sathiadas et al, 2017). About 14% of the screened late-adolescent schoolchildren reported being sexually abused in some way in a study conducted in southern Sri Lanka (Perera & Østbye, 2009).

The 30-year civil war left many families fatherless. An absent male parental figure and adverse childhood experiences are considered to be associated with later intimate partner violence by men. However, in a study conducted in Sri Lanka, being raised in a female-headed household did not increase the risk of later intimate partner violence in adulthood compared with being raised in a household with a male parent, even though adverse childhood experiences, especially sexual abuse, increased its odds (Fonseka et al, 2015).

Cultural influences

Asian societies are known for their preference for a new-born to be a son. Nevertheless, studies in Sri Lanka have shown that there is no son preference. This may be due to the improved status of Sri Lankan women (Abeykoon, 1995). This may translate into improved literacy rates for women, as girls’ right to education is valued by the families in post-war Sri Lanka.

Children traditionally lived with their extended family, usually including grandparents, who influenced the children’s psychosocial development. Standards of living have increased since the end of the war and family systems are changing. Increasingly, the nuclear family lives separately from their relatives, closer to places of work. This may contribute to difficulties with early child care and dependency on paid day care for toddlers.

Some parents may attribute emotional and behavioural symptoms of their children to the influences of evil spirits. People often seek help from spiritual healers before resorting to psychiatric services, which results in delayed presentations. This may be related to the stigma associated with mental disorders among the Sri Lankan population. Furthermore, there are cultural beliefs; for instance, if a parent is unable to discard the first cut hair of an infant appropriately, the child is believed likely to suffer speech delay. Therefore the parents, usually influenced by the extended family, may wait years before seeking medical help, undermining early interventions for developmental disorders such as autism spectrum disorder.

The way forward

The specialist specified training pathway of the Royal Australian and New Zealand College of Psychiatrists and the medical training initiative of the Royal College of Psychiatrists (UK) are providing much-needed training opportunities. This helps to expand Sri Lanka’s human resources in psychiatry. A few Sri Lankan trainees have recently been fortunate to obtain high-quality advanced training in CAP at the Mindful centre for training and research in developmental health in Melbourne, Victoria, Australia, a programme affiliated to the University of Melbourne.

It is hoped that more and more child and adolescent psychiatrists trained in Australia will return to the country. Then they can establish services in needy areas of the country, in collaboration with the relevant authorities, such as the Ministry of Health. If we have proper child and adolescent services then we may be able to prevent many adult psychiatric problems.