As students return to their classroom studies disrupted by the Covid-19 pandemic sweeping the country after months of studying online, many of them will experience new challenges as they struggle to adapt to daily routines and demands that could raise their stress levels and result in serious mental problems including self-harm.
Senior Lecturer, Psychiatry Department, University of Sri Jayewardenepura, and Consultant Child and Adolescent Psychiatrist, Colombo South Teaching Hospital, Dr. Yasodha Rohanachandra tells the Sunday Observer how parents and teachers can help adolescents to cope with these challenges and signs to look out for in a troubled child/adolescent.
Éxcerpts.
Q:There has been a surge among adolescents with suicidal self-harm tendencies in Sri Lanka in recent years, many of them students battling to cope with returning to their daily routines and classroom teaching after a prolonged stay at home. What are some of the main challenges they are likely to experience while adjusting to their former classroom teaching routine?
A. During the pandemic children did not have a daily routine and thus, may struggle with adapting to daily routines, organisation of daily activities, and time management once school commences. Those who did not have access to online teaching may be lagging in academic work, which may add extra pressure on them. Early primary schoolchildren who did not have the opportunity to attend school in person may struggle with social interactions and making friends. Some children may be nervous about being away from home after being at home for a prolonged period. Others may worry about contracting Covid-19, which may make going to school difficult for them.
Q: The pressure exerted on children by parents to perform well academically and participate in several extracurricular activities has often been cited as a leading cause of nervous breakdown in many adolescents and even underage children. Your comments?
A. Several studies carried out in Sri Lanka have found academic expectations to be a major predictor of stress in adolescents. High expectations from parents and teachers, fear of academic failure, academic competition with peers, studying material with minimum interest, having too much homework, and not having enough time for leisure have all been identified as risk factors for stress and anxiety in Sri Lankan adolescents. Interestingly, these studies have revealed that students studying in government schools experience higher academic associated stress compared to students of semi-government or private schools.
Q:There have been recent reports of bullying by peers and harsh disciplinary treatment from teachers. Have these too contributed to the rise in suicidal tendencies among young persons?
A. Misunderstandings and conflicts among colleagues and the inability to make peer relationships are common stressors among adolescents. According to the Global school-based student health survey (GSHS) carried out in Sri Lanka in 2016, being bullied was associated with a significantly higher prevalence of mental health problems such as attempting suicide, loneliness, feeling worried, and substance use. In this survey, victims of bullying were almost five times more likely to report anxiety, and three times more likely to use substances. Bullying is also frequently associated with low self-esteem, depression, and even post-traumatic stress disorder.
Q:What about failure in exams and inability to face parents’ disappointment?
A. In my clinical practice I have come across several children and adolescents who have attempted to harm themselves after not achieving expected results in exams. Shame, embarrassment, fear of parental reaction, disappointment about letting down parents and teachers can all contribute to such acts of self-harm by students.
Q:Broken love affairs?
A. I have encountered many instances where adolescents have attempted to harm themselves following broken romantic relationships. Developmentally, adolescents tend to believe that their experiences are unique and cannot be understood by others. This may make them believe that their love is unique and they will never be able to fall in love again. Or believe that no one else can understand their pain, which may make them not seek help. This, combined with poor judgement, impulse control and decision-making skills that are common to adolescents, puts them at higher risk of self-harm following such incidents.
Q: There have also been instances where constant and harsh physical and mental abuse on children and adolescents by their own parents could lead to self-harm and suicidal tendencies. Although more common in the West, evidence shows it is a growing trend in Sri Lanka as well. Do you have any research on this in Sri Lanka?
A. To my knowledge, there is no research examining child maltreatment and later risk of self-harm in Sri Lanka. However, in my clinical practice, I find that many children presenting with self-harm have a history of abuse or poor parent-child relationships. The parent-child relationship is the first interpersonal relationship experienced by children.
Thus, the parent-child relationship sets the standard for interpersonal relationships in later life. Children who are maltreated by their parents may believe that they are worthless, have low self-esteem and usually have a negative view of interpersonal relationships. They are reluctant to seek help for their difficulties, as they have repeatedly been let down by their parents when they needed help.
In addition, young children are not able to regulate their emotions and depend on parents to help them regulate their emotions. This, in turn, helps them develop their own emotional regulation skills. Experiencing neglect during childhood can hinder the development of these emotional regulation skills, making it difficult for these children to cope with stress and negative emotions. Furthermore, child maltreatment can lead to depression, anxiety, post-traumatic stress disorder and eating disorders. All of the above factors contribute to children who have undergone maltreatment to have a higher risk of self-harm and suicide.
Q:What are the symptoms to watch out for in children and adolescents?
A. Early detection and treatment of depression is important to minimise the suicidal risk in children and adolescents. Parents should look out for recent changes in their child’s behaviour such as recent onset irritability and anger outbursts, lack of interest in previous leisure activities, deteriorating school performance, school refusal, social withdrawal, recurrent complaints of physical symptoms, sleep disturbances, and any changes in appetite, which may all indicate depression.
Any expression of thoughts of self-harm or suicide should be taken seriously and warrants urgent assessment by a psychiatrist.
Q:If they have no one to discuss their problems with, will their elevated stress levels lead to suicidal and self-harm tendencies?
A. Not having anyone to confide in is identified as a risk factor for self-harm. Having to bear their problems by themselves can increase stress and make adolescents feel that they are alone. Having a trusting relationship with parents can help adolescents open up about their problems with their parents.
Parents often try to dismiss their children’s problems by saying “it is not a big deal” or by saying that “other people have bigger problems,” to make their child feel better. However, this can make an adolescent feel that their parents do not understand them and may stop adolescents from sharing their issues with their parents. Similarly, telling adolescents to “get over it” or “to just stop thinking about it” will make adolescents feel that their parents undermine their problems. Therefore, when children come to them with their problems, parents should validate their child’s concerns and acknowledge that they understand why their child may find the situation difficult.
Q:Treatment wise – how do you treat children and adolescents who suffer from such symptoms?
A. If the suicidal thoughts are due to underlying depression, treatment of the depression will lead to improvement of the suicidal thoughts. In children and adolescents, we use a combination of medication and psychological treatment. In situations where there is a high risk of suicide, they may need inpatient care to ensure their safety.
Where significant stressors at home or school are contributing to depression and thoughts of self-harm, measures need to be taken to resolve these stressors.
However, not all attempts of self-harm are due to depression. Sometimes, children and adolescents harm themselves as a way of dealing with distress or emotional pain, without the intention to die.
Although they do not intend to die, there are instances where they suffer serious medical consequences as a result. Therefore, these children and adolescents should also be offered psychological treatment to improve their distress tolerance and emotional regulation skills.
Q:This is also the time when adolescents experience a surge in hormones and changes in their bodies which as they mature could result in visible symptoms such as acne, skin rashes, enlargement of the breasts, voice changes. Studies have shown that while parents should ideally be the first persons whom children should be able to go to, to talk about these changes in their reproductive system, most parents often leave that task to their teachers who in turn leave it to a counsellor. Most adolescents end up learning from their peers or the internet. Your comments?
A. Parents are, of course, the best people to educate their children about puberty and sex. This should ideally start from young ages and proceed throughout their childhood and adolescents in a developmentally-appropriate manner. For example, young children need to be educated that they have the right to their bodies and they should not allow anyone to touch them inappropriately. Older children need to be educated about changes in puberty, safe sex, risk of pregnancy, and sexually transmitted diseases. However, as parents often do not educate them about these matters, they turn to their peers. Their same-aged peers are also usually misinformed and are unlikely to provide them with useful information. Obtaining sex education from the internet can be dangerous. The information given on the internet may not be accurate or true. Therefore, adolescents who obtain sex education from the internet may develop myths about sex and may come to accept certain abnormal sexual acts as normal.
Q:Safeguarding children and young people from violence and abuse resulting in extreme steps like suicide is already enshrined in our Constitution. How do you fill in the gaps that still remain open leading to such extreme steps?
A. Addressing the risk factors for abuse, such as poverty, substance use, and parental mental illness is important in reducing the prevalence of child abuse. In addition, improving community child protection services and ensuring proper penalties to perpetrators would also help to reduce this problem.
Q:Your message to all students returning to school under the new normal?
A. Returning to normal life after a prolonged period of school closure can be challenging. It may take some time for you to completely adjust to the new normal.
However, it is important to remember that you are not alone and that many adolescents out there are faced with the same problem. If you need help and advice from trained counsellors, it is available.
Q:Who should they contact?
A. All hospitals have a Yowun Piyasa where youth can obtain counseling services and advice. In addition, they can contact the helpline of the National Institute of Mental Health (NIMH) on 1926 if any help is needed.