Methodologies and skills in child and adolescent mental health, psychosocial care, and protection: A repository of training and intervention materials

In India, there is vast gap between child and adolescent mental health needs, measured through burden of disease estimates and resource availability.[1] The emerging needs of children, especially in low socioeconomic urban contexts are becoming increasingly complex. Within the juvenile justice system, children in need of care and protection come from increasingly challenging backgrounds. Many of them experience enormous developmental deprivation and experiences of trauma, loss, and grief. At one level, for example, the impact of various types of physical/sexual abuse, which are assaultive, forms a complex context for trauma intervention. At another level, children in conflict with the law are becoming an increasingly challenging group to work with, especially where their alleged offences involve acts of violence or sexual assault. There are other confounding contexts such as substance abuse, gender-based violence, and adolescent developmental challenges (normative sexuality versus teenage pregnancy). Within the vulnerable group of street children and orphan/abandoned children, are subgroups such as HIV infected/affected whose difficult social situations are compounded by medical needs, neurodevelopmental problems, and complex psychological issues relating to loss and trauma. And then, children with disability may form part of the above categories and/or a separate category of their own – for example, there are children with a range of disabilities, from locomotor and sensory disabilities to intellectual disabilities and specific learning disabilities. Thus, child and adolescent mental health have fast grown into a critical public health issue, requiring systematic approaches to awareness, prevention, promotion, and cure.

However, most child and adolescent mental healthcare services are located in tertiary healthcare facilities; they are few in number, thereby limiting access to many in need.[2] Further, many have a solely curative focus rather than combining this with promotive and preventive activities. Many tertiary care professionals believe themselves to be “too specialized,” unfortunately, to assist primary care and community-based agencies and child care workers and prefer to restrict their sphere of work to their clinics. They also tend not to acknowledge the links between child protection and child mental health, thereby not serving large groups of children whose mental health issues are closely entwined with legal issues (such as children who are sexually abused and/or children in conflict with the law).

Where nonspecialist care is concerned, there are many community-based agencies that provide care and protection to children in difficult circumstances; the Integrated Child Protection Scheme staff, Anganwadi workers, and government school teachers are other types of community-based child care workers tasked with child psychosocial well-being, in direct and indirect ways. A number of nongovernmental agencies are also involved in providing child psychosocial and mental health care, including treatment, rehabilitation, community-based care, and awareness and prevention services.[1] However, community-based providers often lack the knowledge and skills required to address child development and mental health in ways that respond to context-specific, often more complex needs, psychiatric problems, or life-skill issues that children and adolescents come with.

Since the Alma Ata Declaration, 1978, numerous medical and health problems, particularly under five disease and nutrition concerns, have made their way into primary health care and community-based health care. Consequently, impressive gains have been realized with reductions in child morbidity and mortality.[3] However, the public health community has only recently begun to acknowledge its role in the mental health of children and adolescents.[4] Due to the emerging imperatives of violence, abuse, protection, and a host of other behavioral issues, in the wake of consumerism and technology, it is now gradually turning its attention to more population-based initiatives and strategies.

Despite the community mental health movement being over four decades old and the current revitalization of the National/District Mental Health Programs (DMHPs), initiatives herein have been largely adult-centric. The Rashtriya Bal Swasthya Karyakram (RBSK), a school health program which focuses on disease, defects, deficiencies, and disability, has not entirely capitalized on its opportunity to address mental health issues in pre-schoolers and in school children; due to lack of systematic screening pro formas and methods, children with developmental disabilities and mental health issues are not being properly identified and are consequently unable to access early intervention and care.[5] Similarly, the Rashtriya Kishore Swasthya Karyakram (RKSK) whose objective is to focus on various adolescent health issues, including sexuality and violence, has also not proactively addressed adolescent mental health issues. It appears that much of the reason why the DMHP, RBSK, and RKSK have not utilized the opportunities they have is related to paucity of field methodology and child mental health skills in service providers.

In response to the paucity of child mental health services and in recognition of public child mental health needs, the Department of Child and Adolescent Psychiatry, NIMHANS, has, with the support of the Department of Women and Child Development, Government of Karnataka, been implementing a community child and adolescent mental health service project, since 2014. It has been providing preventive, promotive, and curative mental health services to vulnerable children and adolescents in the state, in primary healthcare centers, anganwadis, government schools, and various types of government and nongovernmental agencies that serve children in difficult circumstances. The project is also engaged extensively in training and capacity-building initiatives for government and nongovernment staff across the country as well as for neighboring SAARC countries.

Our experience through the above-described project consistently reflected the paucity of methodology in child work. Many child care service professionals in primary, secondary, and tertiary agencies and institutions, whether in health, education, welfare, or legal sectors, frequently expressed that there is a general unavailability of contextually relevant and culturally suitable materials to work with children and adolescents, to address their mental health and psychosocial care needs. Existing materials tend to have been developed in and for western contexts; what has been developed and used in the Indian context is also scattered and not easy to access and/or not relevant to common contexts of child mental health work such as abuse, trauma, loss and grief, sexuality and conduct issues, to name a few.

One of the key mandates of the Community Child and Adolescent Mental Health Service Project, therefore, has been to create and develop mental health and psychosocial care-related materials for use by child care service providers of various types and cadres. Assessment pro formas, activity books, and training manuals have all been developed through extensive field work and continuous iteration, revision, and refinement processes through our learning from children and child care workers. All the materials and methodologies developed have been consolidated into a website (http://www.nimhanschildproject.in). As we continue to work in the field and gather more experience, more material will be added to this repository and website – thus, it will be constantly updated and refined.

We have a “Copy-Left” policy – so, we encourage child mental health practitioners and child care service providers to actively use and experiment with the materials and methodologies that we have developed, for, this is the only way in which meaningful assistance can be provided to children, and result in transformations in their lives.