A child’s brain develops rapidly in the first five years when it is most sensitive to environmental stimuli. It is during this period that new learning can easily take place.
The hitherto sidelined critical health issue of psychological impacts on children born with disabilities apart from their physical impacts was highlighted at the recently concluded 9th Confab on Birth Defects and Disabilities and brought fresh insights into this health issue.
Senior Lecturer, University of Sri Jayewardenepura and Consultant Child and Adolescent Psychiatrist, Colombo South Teaching Hospital Dr Yasodha Rohanachandra tells the Sunday Observer why such children need early therapy and discusses gaps that need to be filled to meet rising demands for such children.
Exceprts…
Q. The 9th International Conference on Birth Defects and disabilities. brought together several professionals working for the welfare of children. Recent studies show that nearly 6,000 babies are born with a birth defect. As a psychiatrist and one who has been closely involved with children with such handicaps, how does this affect the child’s psychological and mental development?
A. Physical disabilities may have a detrimental effect on cognitive and psychological development. Such effects are more likely to be seen when the physical disability affects the brain. In instances where the brain is affected, it may cause intellectual disability or mental retardation, where a child’s ability to learn, reason, make decisions, solve problems and day-to-day skills are impaired. In addition, physical disabilities may affect the child’s social development, e.g. if a disability limits the child’s mobility, the child may find it difficult to keep up with his peers during play. Certain disabilities may also cause difficulty in communication. In both instances, the child will have difficulty in maintaining friendships and be socially isolated.
Limitation of physical function due to the disability may also cause anger and frustration. The child may eventually take this out on others, which may be seen as behavioural disturbances.
Q. Early signs to look out for in children with such handicaps?
A. As a Psychiatrist, we pay special attention to the speech, cognitive and psychological development of these children and observe for any early signs of speech, social or cognitive delays. For example, if by one year a child is unable to say a single word, or if by two years a child cannot combine two words to make short meaningful phrases, we suspect there is a delay in language development. Similarly, if by three months a child does not smile, or if by one year a child does not wave bye-bye or by three years if a child does not like playing with other children, we can suspect that his or her social development is impaired. Furthermore, if by two years a child is unable to understand simple commands, by five years he or she does not know their name, age or has difficulty in identifying colours and by six years has poor understanding of days and months or has difficulty in identifying letters and numbers, it gives a clue that the child has a delay in cognitive development. In addition, we also look out for any behavioural disturbances in these children such as aggression, self-injury and sleep disturbance.
Q. I read that Juvenile Idiopathic Arthritis which is also a crippling disease attacking children under 16 years is still a veiled disease. How does this disease impact on them mentally?
A. A child with Juvenile Idiopathic Arthritis (JIA) may experience pain and physical limitations. This may cause difficulty in performing daily classroom activities. They may feel concerned about their body image; have anxiety about social acceptance, and fears about prognosis and treatment. Also, frequent visits to the doctor may cause school absenteeism resulting in poor school performance. Furthermore, children with JIA may experience sleep disturbances due to pain. Therefore, they are at a higher risk of developing mental health problems such as depression and anxiety.
Q. How do you address them and slow their progress?
A. Early identification of any speech, social or cognitive delays is of utmost importance. In the first five years of life the child’s brain develops rapidly and is the period where the brain is most sensitive to environmental stimuli. Hence, the first five years is the period where new learning can most easily take place. Therefore, if any delay is identified within the first five years, it will be easy to correct through therapy. To improve their development and skills we engage the child in various activities including speech therapy, occupational therapy, social skills training etc. as required.
Q. There are also new emerging diseases that seem to be surfacing in young children resulting in life long scars and disabilities . Can you name a few that can prevent a child from achieving his/her maximum potential and affect his development and growth?
A. Infections acquired during pregnancy such as rubella can cause children to have effects on development and growth. In the recent past, Zika virus was identified as being associated with developmental delays and intellectual disabilities. In addition, the use of alcohol or illicit drugs during pregnancy can cause birth defects, developmental delays or behavioural disturbances. Unfortunately, we are now beginning to see more children being affected by the mothers’ alcohol and substance use.
Q. Juvenile diabetics – do they also fall into the category of children with disabilities? How does this particular ailment affect the child?
A. Management of diabetes in children usually involves having insulin injections several times a day, regular monitoring of blood glucose levels and careful meal planning. As you can imagine, this type of treatment regimen may interfere with their leisure activities and peer relationships and can cause significant stress. Children with diabetes may also require recurrent hospital visits to manage their blood glucose levels, leading to school absenteeism and deterioration of school performance. For these reasons, diabetes in children is known to be associated with mental health issues such as depression, anxiety and disordered eating.
Q. Children with cleft lip or palates, down syndrome, those born with clubfeet – are deformities that can cause low self esteem and other mental problems. As a psychiatrist how do you deal with these children?
A. Rather than focusing on the deformity and what the child cannot do, we focus on the child’s strengths and what he can do. Focusing on the child’s strengths and talents and helping them to improve these talents would help to overcome the low self-esteem.
Q. Role of parents, teachers and guardians in helping these children to develop?
A. Parents should be the biggest advocate for their children. They are the people who spend the most time with their children and therefore have more opportunity to assist them to develop their skills. As mentioned earlier, they should pay more attention to what their children ‘can’ do rather than focus on what they cannot do. Comparing their children with others would only lead to the worsening of the child’s self-esteem.
Teachers need to understand the limitations of the child due to his illness and the associated psychological impact.
If there is an intellectual disability, these children may need individual educational plans and extra attention. We often find that children with disabilities are bullied by their peers in the classroom. It is the teachers’ responsibility to act against this sort of bullying and make sure the child is physically and emotionally safe in the classroom.
Q. Gaps you see in the psychiatric services available to such children in our present health care system?
A. Most children with disabilities require services such as physiotherapy, speech therapy and occupational therapy. However, these services are not often found in peripheral hospitals and are not easily accessible. Therefore, community based programs should be initiated in order to make these services accessible to all.
Q. Do you think special schools with trained teachers in child psychology and child friendly equipment designed especially for children with specific needs is the answer?
A. Not all children with disabilities will require special schooling. Most can be managed in mainstream schools with extra support. Special schools should be reserved for children with severe disabilities.
Q. Are there enough such schools to serve the growing number of children with disabilities in Sri Lanka?
A. According to the census 2012, 95.7% of persons with disabilities were not engaged in educational activities. Several strategies can be implemented to overcome this issue. Firstly, more resources should be provided to mainstream government schools so that they can accommodate children with special needs in their classrooms. At present, due to the high student teacher ratio in mainstream schools and the exam-oriented nature, children with disabilities are not able to receive the extra support they require. Secondly, giving more attention to training teachers on inclusive education and special education would be helpful to manage children with different needs in the same classroom. Increasing the number of special units is also an option.
Q. Do you recommend a set of guidelines for teachers and carers to follow and strict monitoring of schools teaching children with special needs?
A. Guidelines need to be formulated for teachers about certain aspects such as student-teacher ratio, environmental modifications to suit children with special needs and facilities available. However, every child will need to be assessed on an individual basis to identify his skills and an individualized educational plan to suit the needs of the child should be formulated.
Q. Have you a message from a psychiatric point of view on how such children can be helped towards reaching their optimal functioning?
A. By focusing on their strengths rather than weaknesses, giving opportunities to build up on their strengths and talents, giving opportunity for normal social interactions, being patient when they take time to learn skills, advocating the rights of these children and most importantly never giving up on them.