Mental health literacy must improve

‘A national child mental health literacy initiative is needed to reduce childhood mental health disorders’ viewpoint by Tully et al. (2019) published in the Australian and New Zealand Journal of Psychiatry is to be commended. A similar view about adult mental health literacy was expressed earlier. The aim of both is to increase awareness of mental ill-health, seek treatment early and prevent increasing morbidity and mortality. Mental health literacy for childhood disorders has been largely overlooked, though clinicians daily see children and parents present, after languishing in silence or seeing counsellors for help with serious disorders such as separation anxiety, one of the most common anxiety disorders in children with 4–10% experiencing it (Mash and Wolfe, 2010) and a third of whom will persist into adulthood (Shear et al., 2006). When combined with social anxiety, it may lead to extreme school refusal, underachievement, family disruption and its sequelae – depression and self-harming behaviour. On an average, a 13-year-old presenting with school refusal and separation anxiety will often give a history of difficulties that spans 3 to 4 years during which time parents will be unaware or continue to have the impression that it will get better, find simple explanations for the problems, obtain advice which they may take or leave and in the latter case take refuge in home-schooling. This improves the anxiety displaced on school but still interferes in normal social activities with serious consequences. There is most often a positive family history of anxiety disorders with a parent(s) who can trace problems to their childhood.

Childhood between the ages of 9 and 12 years was described as a stage of quiescence, while adolescence was supposed to be a time of turmoil. Both were considered to be normal, but we now know that by age 8 to 9 years, children experience mental health difficulties but are not sufficiently developed cognitively to clearly communicate their distress. Children are dependent on their parents and caregivers, who, despite mental health education, have to contend with their own human qualities, i.e., their own life experiences and personalities. Shame or guilt about having a child with emotional difficulties, coping by denial, dismissing concerns with ‘it’s probably a phase – all adolescents go through moods’ – is to be considered. On average, there is a gap of 2 to 3 years between a child experiencing problems and a parent becoming aware. At times, they lack the knowledge of who to see – a paediatrician, a psychologist, a counsellor – often settling for the first, because of less stigma, or they fail to see anyone. It is not always the fear of being stigmatized, or the lack of knowledge. This is clearly illustrated by the reactions of different parents to diagnosis. The sense of relief experienced both by the child/adolescent and parents is palpable, when they are told that their child has obsessive-compulsive disorder (OCD) and that it explains to a large extent the turmoil they have been experiencing. Another parent may react with disbelief and seek a second opinion. When a child is diagnosed with mental illness if he or she needs something to identify with in the absence of all else, the mental illness may become a source of identity which should be carefully addressed. Children often state that they keep their rituals ‘secret’ for fear of being thought of as ‘Mad’ as well as the real fear of ‘going mad’. When the child experiences the clinician as ‘knowing’ them, there is an immediate open-ness which never ceases to be a pleasurable experience for the clinician.

The greatest disservice we have done to children is heeding advice not to diagnose childhood disorders as we would those in adulthood, not to use medication for children and adolescents and not to diagnose personality disorders in the under 18’s. It is apparent that psychologists who are on the frontline for referrals often refer back to general practitioners to prescribe medication for children unresponsive to their psychological interventions over time; we continue to see early adolescents who meet all criteria for personality disorders which continue to be troublesome later. The prevalence of trauma must not be forgotten.

If parents leave their children to ‘find their own language to author their own lives’ (Samuel, 2020), we will be responsible for mental illness being ‘the chronic diseases of the young, beginning in childhood and adolescence and affecting the core areas of life, including education, achievement, relationships and occupational success’ (Kessler et al., 2005). More than ‘sticky labels’ (Samuel, 2020), there are childhood mental illnesses that unfortunately never go away. Young brains require mature guidance in real time in order to be equipped to later make choices. A properly designed and implemented childhood mental health literacy programme is long overdue.