|Year : 2017 | Volume
| Issue : 1 | Page : 4-7
School mental health programme in Maharashtra - Today and way ahead
Kishor Gujar1, Varsha Pingale2
1 Department of Psychiatry and Child Guidance Clinic, Pimpri, Pune, Maharashtra, India
2 Yashwantrao Chavan Memorial Hospital, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||19-Jun-2017|
C-5, Mayurban Society, 1100, Shivajinagar, Model Colony, Pune - 411 016, Maharashtra
Source of Support: None, Conflict of Interest: None
Positive mental health is, and should continue to be the basis of all the mental health policies of any country. The scarcity of well-documented school mental health (SMH) activities and the data for the region of Maharashtra is the main rationale behind this review article. After reviewing some important studies related to SMH in India, the SMH data at Child Guidance Centre of Yashwantrao Chavan Memorial Hospital in Maharashtra, will be used to discuss and propose a guideline for further SMH activities in Maharashtra. SMH program is the best way to cater to the current and future demand of mental health services and to improve overall child and adolescent mental health.
Keywords: Child and adolescent, Child Guidance Centre, Maharashtra, school mental health
|How to cite this article:|
Gujar K, Pingale V. School mental health programme in Maharashtra - Today and way ahead. Ann Indian Psychiatry 2017;1:4-7
| Introduction|| |
The best of the online search engines related to scientific research, scholarly articles, or public surveys yield no significant results if the key/search words are “school mental health in Maharashtra.” Hence this effort is to discuss the already published important review or research literature across India. Children and adolescents constitute almost a third (2.2 billion individuals) of the world's population. Almost 90% live in low- and middle-income countries (LMIC).
Our article aims at offering the data from the Child Guidance Centre (CGC) of Yashwantrao Chavan Memorial (YCM) Hospital as a very first published school mental health (SMH) data that serves as formal documentation for the region of Maharashtra. This article is the first attempt to publish SMH service-related data for Maharashtra, in a journal that follows internationally recognizable standards of publication. There is an enormous and overall gap between the mental health needs and available resources. According to the 2011 census, the population of India is 1.206 billion. More than 45% of this population is below the age of 20 years. Thus, children and adolescents form a major proportion of our country. Various policies in India do recognize the need for the holistic development of children, and therefore, the various national and regional programs should be planned and implemented in lines with this goal. There is a high prevalence of externalizing disorders among boys and internalizing disorders among girls. To make child guidance effective, affordability, availability, accessibility, acceptability, and appropriate technology form the basis in child mental health.
| Understanding the Enormity of the Problem|| |
Bhola and Kapur  reviewed 55 studies (1964–2002) on child and adolescent psychiatric epidemiology in India. The 21 community studies reflected a prevalence of 0.48%–29.40% across disorders such as mental retardation (MR), epilepsy, enuresis (frequent) and depression, anxiety, and obsessive–compulsive disorder (infrequent). The 23 school-based studies (1978–2002) reflected a prevalence of 3.23%–36.50% across disorders such as enuresis, MR, externalizing disorders (e.g., conduct disorder/attention-deficit/hyperactivity disorder [ADHD]). All children face some or the other, major or minor mental health problems during the age group of 6–17 years. Learning being an important aspect of development, the schools are ideally the system that is set up to meet the crucial goals of learning; either through formal education or through life skill education activities. Malhotra and Patra  in their systematic review and meta-analysis of the child and adolescent psychiatric disorders found a prevalence of 6.46% in the community and 23.33% in the school setup. This was the first meta-analysis of its kind determining the epidemiology of child and adolescent psychiatric disorders in India, and it showed how inadequate are the reporting systems of psychiatric disorders in children.
| Why Put Mental Health Services in Schools?|| |
Schools are places where the students come together and spend most of their time with peers and teachers. According to the World Health Organization (WHO), mental health is “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” The parliament, in its Tenth Five Years Plan, incorporated the necessity for the mental health research at the community level. It stated the need to focus on substance abuse and on developing child and adolescent psychiatric clinics. As an essential mental health care goal, the Eleventh Five Years Plan of the district mental health program added life skill education, suicide prevention services, and counseling at school and college levels. Conducting mental health activities at school level improves the chances of children's access to mental health or any other services for that matter. Their families too feel more comfortable seeking help in a community setting (like schools) as it minimizes the problems related to transportation, accessibility, affordability, and a perceived stigma associated with it. School settings provide additional opportunities to observe children and intervene directly in school setting if required. This results in clinical efficiency and productivity as long as mental health services are concerned.
An ability to collaborate with and advocate for the educational needs of a student ensures further opportunity to reach out to those with internalizing disorders. Along with the ease of accessibility and affordability, SMH services become a multidisciplinary entity that involves teachers, families, mental health service providers, and school administrative bodies. To enrich the SMH continuum to its fullest, the extended stakeholders such as business leaders, journalists, advocates, and the legislators need to be involved too. An integration of all primary caregiving systems and their coordinated efforts fosters the overall mental health of students. This type of network will not only prevent late special education referrals but will also reduce time and costs required for the primary and urgent care. In addition to improving educational outcomes, SMH programs as an inbuilt system will result in decreased high-risk behaviors (such as violence and substance abuse). This system is helpful in decreasing the accidents, suicides, and homicides that constitute the public health mortalities for our children.
Early identification of and timely pharmacological interventions for ADHD reduce further risk of multiple psychiatric disorder. Suicide is the third leading cause of death among children aged 10 years and above. Maximum psychiatric disorders are manifested in the form of ADHD in their early stage. Our failure to intervene early in a child's mental health problems results in higher educational costs and will cost us a dramatically lower graduation rate. An increased use of expensive “deep-end” mental health services will be required further adding to the overall health care costs. An increased number of children in the juvenile justice system and at other out-of-home placements would follow from this situation.
| School Mental Health Programme in Maharashtra|| |
Tata Institute of Social Sciences in Mumbai, pioneered in Maharashtra, to start a CGC in 1935. References of early SMH activities in Maharashtra, were found in an article  which states that Dr. H.S. Dhavale headed SMH activities in 1979 at Nair Hospital in Mumbai; he also set up SMH clinic in 1982 and continued SMH activities as a part of student enrichment program. Sarv Shiksha Abhiyan (SSA) has been running multiple school health activities all over the nation from 2000 to 2001, and they continued to modify the services related to SMH too. WHO  had put forth what an effective School Mental Health Programme must take into account: relationship between the school and community environment, the unique cultural values and identities, the sociopolitical conditions and processes, family and community members, skills of school and community mental health professionals, multiple levels of intervention, current and possible coordinating mechanisms, teachers, parents, program modification, etc. Above factors were reflected into SSA activities at Pimpri Chinchwad Municipal Corporation too. Some of the clinical and mental health goals were realized (more concretely 2008 onward) to their best possible level in our activities at CGC at YCM Hospital, Pimpri. Not surprisingly, the CGC activities and SMH data [Table 1] at the department of psychiatry in YCM Hospital reflect a high need for mental health intervention among school-going children and adolescents.
| School Health Report|| |
In 2008, the psychiatry department and CGC at YCM Hospital had conducted a 1 day awareness program for the local school teachers and local population. This program included a day long poster presentation and expert guidance to teachers and school principals (classroom modifications for common psychological and behavioral problems of children, role and nature of psychological assessment, etc.). Soon after this, the reference system and documentation of problems were improved drastically. Involving resource people from the education department, school teachers, and school principals proved to be helpful in setting up a network to supervise the progress of intervention. The SMH reports at YCM Hospital for the years 2008, 2009, and 2010 reveal that the good follow-up rates help in exploring comorbidities and in arriving at a specific diagnosis (mainly MR, ADHD, specific learning disorder, anxiety, depression, seizure disorders, stuttering, enuresis, behavioral disorders, speech and hearing difficulties, etc.).
An extensive review by Murthy dealt with the policies pertaining to children in India. It revealed the lack of clear-focused policies on child mental health. The uncoordinated efforts of the various (welfare, education, labor, health, law) sectors and changing or unrealistic targets were the associated reasons behind this lacuna. He proposed it to the existing mental health professionals of the country to reach out beyond their usual clinical preoccupation. He proposed one of the most effective intervention models for the country like India. Along with the Anganwadi workers and school teachers, an “in-field” resource team could be formed at a school level. Anganwadi workers could be helpful in the following areas: early recognition of preschool children with problems, providing first aid in emergencies, carrying out preplanned mental health promotion activities for stimulation at the day care, guiding parents about parenting skills, and further references. School teachers could play an important role in early identification of childhood problems and further referral to health facility (e.g., detection of sensorial defects). Teachers could help in providing first aid in emergencies, educating children regarding mental health, accident prevention, risk-taking behavior, drug abuse, etc., Along with the methods to increase self-esteem through life skills education, the teachers could facilitate parental counseling related to adolescent issues. Clinical psychologist could reach out through health workers, voluntary agencies, teachers, police, and village leaders. They could facilitate activities that involve psychosocial treatment, SMH, research in public mental health, developing effective teaching and assessment methods.
| Challenges in School Mental Health|| |
Researchers have emphasized telepsychiatry in SMH as a necessity in developed countries like the USA as 14%–20% of the child and adolescent population has mental, emotional, and behavioral problems. Out of that, 70% diagnosable population does not receive treatment. In 2020, 8300 child and adolescent psychiatrists will be required in the USA, and it will only be the one-third of the total requirement by then. Telepsychiatry could help reduce this huge gap to some extent through SMH activities. Limited resources is the biggest challenge. Insufficient funds is at the basis of all challenges related to capacity building, imparting the skills to mental health staff, financing the awareness activities, and keeping the activities rooted to the cultural needs rather than blindly following the international norms and priorities. Our government and nongovernment organizations need to have formal bodies to evaluate the state of the art issues and current challenges. We will benefit from drawing out a plan and prioritizing the needs wisely to facilitate the most groundwork that is required at the school level. Implementation of those plans diligently and the documentation and quantification of the results must follow too. We thus have a lot of work to do to qualify as leaders of our community mental health and the well-being in general. SMH must invest in identifying the willing and able friends for our children.
A review finding  indicates that the mental health promotion and interventions for young people can be implemented effectively in LMIC. School-based programs and multicomponent community-based studies are proved to have a strong positive impact on the well-being of young people. The authors discussed the feasibility and effectiveness of integrating mental health promotion interventions into education and community programs. The examples include community empowerment, poverty reduction, HIV/AIDS prevention, reproductive and sexual health. Vranda from NIMHANS proposed development of a comprehensive model/program on “Promotion of Mental Health and Psychological Well-Being of Adolescents in Schools.” She counted on teachers as facilitators to implement the activities with participatory experiential approach. The goal should be to promote mental health and well-being of adolescents and to enhance psychosocial skills for increased resilience.
A full continuum of SMH services includes the following:
- Universal prevention services are provided to all the students who seek promotive positive mental health and educational success (e.g., life skill education)
- Targeted prevention and intervention services focus on high-risk groups that seek to improve social-emotional skills and behaviors that are linked to positive mental health and educational success
- Intensive intervention services cater to the needs of affected children. They help students cope up with the social, emotional, and behavioral issues that impact positive mental health and educational success.
| Conclusion|| |
If developed and implemented well, SMH services can ensure that all students have an equal opportunity to develop to the fullest of their capabilities (cognitive, social, and emotional). Mental health professionals along with the youth, family, school teachers, community health staff, and the community at large can contribute substantially into SMH goals. It is the most suitable answer for all the current challenges involved in mental health care in India. For the developing countries like us, there is a long way to go before we could have a reliable and effective mental health system. Not only for the region of Maharashtra, but also across India, the foremost step would be to work in the existing setup and available resources by enriching SMH activities.
What J. Krishnamurthy stated forms a philosophical guideline for us regarding what school mental health programs should aim at……, “…education is to see that when child leaves the school, he is well established in goodness – both outwardly and inwardly.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barry MM, Clarke AM, Jenkins R, Patel V. A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 2013;13:835.
Bhola P, Kapur M. Child and adolescent psychiatric epidemiology in India. Indian J Psychiatry 2003;45:208-17.
] [Full text]
Shastri PC. Future perspective of planning child guidance services in India. Indian J Psychiatry 2008;50:241-3.
] [Full text]
Malhotra S, Patra BN. Prevalence of child and adolescent psychiatric disorders in India: A systematic review and meta-analysis. Child Adolesc Psychiatry Ment Health 2014;8:22.
Gujar K. School mental health reaching the masses. In: Different Strokes. 1st
ed. Kolkata: Indian Psychiatric Society; 2015. p. 25-31.
Biederman J, Wilens T, Mick E, Spencer T, Faraone SV. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999;104:e20.
Grady BJ, Lever N, Cunningham D, Stephan S. Telepsychiatry and school mental health. Child Adolesc Psychiatr Clin N
Vranda MN. Promotion of mental health and well-being of adolescents in schools – A NIMHANS Model. J Psychiatry 2015;18:303.