Do we even recognise anxiety and depression in our children? Based on local research, the country's overall mental health literacy is still low. — Photos: Freepik
I AM writing from Britain where I’m currently a Jeffrey Cheah Scholar-in-Residence at Brasenose College, University of Oxford for a month, to explore research collaborations at the Department of Experimental Psychology.
One of my conversations with a researcher here prompted me to write this article. It went something like this:
“How is the CAMHS (Child and Adolescent Mental Health Services) like in Malaysia, Alvin?”
“We don’t have CAMHS, I’m afraid. There isn’t enough human resources to form CAMHS,”
“Oh, then where do children and teenagers with mental health problems go?”
It was a good question that got me thinking: What do we do when children suffer from mental health issues such as anxiety and depression?
Firstly, do we even recognise anxiety and depression in children?
Based on my readings of local research and my personal experiences as a mental health professional, unfortunately, the overall mental health literacy in Malaysia is low; even lower when it comes to child and adolescent mental health.
Mental health services in Malaysia tend to focus on adults, and there are very few mental health professionals such as psychiatrists and psychologists who specialise in children and adolescents, compared to those who see adults.
In recent years, the National Health and Morbidity Survey have reported heightened depression and anxiety in children and adolescents, especially after the Covid-19 pandemic.
Such an observation is not unique to Malaysia. It is also a worldwide phenomenon; young people are now more vulnerable than ever to mental health issues.
Triple burden
So, we have a triple-burden problem: (1) Poor mental health literacy surrounding child and adolescent mental health, (2) severe shortage in the numbers of mental health professionals, and (3) a significant rise in mental health problems among young people.
What can we do? Well, I think we can outsource some of it.
Outsource to whom, you may ask. One answer is outsourcing to teachers at school.
The gap in mental health service for children in many countries is huge. Many children who need help are not getting it. So, going into schools to provide intervention to minimise risk and improve well-being can help to bridge that gap.
This is something that Britain has been working on. Psychologists are co-designing intervention programmes with schools to provide better access to interventions facilitated by teachers to reduce anxiety and depressive symptoms in children, especially where mental health services are absent.
There are various school-based interventions by coordinated teams of mental health professionals, teachers and relevant organisations.
Lead researcher of The Oxford Psychological Interventions for Children and adolescents (Topic) Professor Cathy Creswell commented that the focus on such school intervention is more on problem solving skills and empowerment, rather than therapy because there are many other factors to be considered for therapy, such as bullying and existing behavioural problems.
Prof Creswell also added that qualitative studies in her research have found spillover effects with parents learning about providing the abovementioned structured support. It is also useful for the child’s siblings, other family members and friends.
One of her projects, the iCATS-i2i (Identifying Child Anxiety Through Schools-identification to intervention) looks into developing and evaluating a new way of identifying children with anxiety problems so that initiatives can be designed to provide these children with effective support.
Much of her research have borne fruit. Parents and teachers get to work together to address emotional problems successfully.
It is important to note that in such cases, teachers are not therapists delivering treatment, but agents of teaching effective skills to cope with challenges as well as adaptive behaviours.
Such initiatives have been found to be successful in schools around the world. An example is the Super Skills for Life (SSL) module developed by Professor Cecilia Essau of Univesity of Roehampton, Britain and Professor Thomas Ollendick of Virginia Tech, United States.
It uses the train-the-trainer model where school counsellors are trained to provide a series of group-based resilience training for early secondary school students.
These training includes self-care skills and understanding the importance of sleep, physical activity and nutrition using fun activities. It also has problem-solving and socialisation components to empower children and teens to be empowered to address challenges actively.
Studies from 21 countries have shown SSL to be effective in reducing emotional problems, recovering faster from a stressful task, preventing the development of an anxiety disorder and improving social and communication skills.
It is an effective programme to tackle the escalation of anxiety and depression, which can be easily and cost-effectively implemented in school.
The training has built capacity and shaped the practice of approximately 25,000 practitioners and has produced positive mental health outcomes in almost one million young people globally.
Going into schools to provide intervention for mental health issues helps minimise risk and improve students' well-being.
Reduction in depressive and worry scores
In Malaysia, a primary school version of the SSL module was successfully carried out in Sarawak recently, led by psychiatrist Dr Bernard Ting Chuong Hock and his team from Universiti Malaysia Sarawak (Unimas), with participants showing significant improvements in well-being with reduction in depressive and worry scores, as well as an improvement in emotion regulation.
At Oxford, doctorate candidate Helen Manley looked at how primary school staff, rather than just teachers, can use their day- to-day classroom practice to better support children with anxiety.
What she discovered was there seem to be two main contributors to increased anxiety in the classroom: (1) pressure and (2) uncertainty. As such, she recommended that school teachers as well as any relevant staff help reduce pressure and uncertainty.
This can be done by increasing predictability, cultivating connection, managing the environment and providing structured support and personal empowerment to solve problems to students in the classroom.
“Increasing predictability includes the use of clear, well-explained, understood and embedded routines as well as consistency of behaviour among teachers and staff. It also helps that children feel that the adult has control over what’s happening so they don’t need to worry or panic about trying to work out what to do themselves. It’s important to be in control while not taking away children’s own sense of autonomy,” said Manley.
Building bond
Cultivating connection is about meaningful, clear, two-way communication. It is important not only between teacher and child but also teacher and parent and teacher and teacher.
This may involve showing interest in the child beyond academic ability, such as remembering things about them, or their family, being open and approachable to parent input and proactively seeking it.
Manley added: “Providing time to ask questions/think/talk/calm down after moments of difficulty can also facilitate better connection between child and teacher.”
Managing the environment involves providing a friendly and conducive classroom layout and organisation of resources so that they are not cluttered and disorganised, but are clearly labelled, with space between tables so children don’t feel squashed in. It also involves managing noise levels, thinking about sources of overstimulation and about alternative quiet spaces for anxious children to move to.
Structured support is about teaching children about tools they can use to overcome challenges or difficulty, rather than avoiding things they find challenging or anxiety-inducing.
For example, Manley explains: “This includes setting goals (with parents and staff), teaching them how to break down problems into smaller chunks and helping them predict their fears and then try it out and reflect on their experiences, ie, was it as bad as they predicted? better? different?”. Research have shown that such problem-focused approach can help empower children to manage their emotions better, compared to just emotion-focused coping.
Together with schools, parents, mental health professionals and researchers can work together towards promoting resilience and well-being in children and teenagers, reducing the risk of mental health issues that we are now seeing more of.
Unwell children may mean trouble for everyone. And therapy is not the only way to achieve better well-being. Most importantly, we all need to chip in and collaborate to prepare a better future for our children.
Dr Alvin Ng Lai Oon is a professor at the Department of Psychology, School of Medical and Life Sciences, Sunway University. He is a clinical psychologist by training and is passionate in promoting mental health literacy in the community.
