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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 33  |  Issue : 3  |  Page : 233-239

UNARV: A district model for adolescent school mental health programme in Kerala, India


1 Department of Child health, SAT Hospital, Thiruvananthapuram, Kerala, India
2 Department of Forensic Medicine, Government Medical College, Thiruvananthapuram, Kerala, India

Date of Web Publication14-Sep-2017

Correspondence Address:
R Jayaprakash
Additional Professor of Paediatrics, Child Psychiatrist, Unit chief, Behavioural Paediatrics Unit, Department of Child health, SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9962.214591

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  Abstract 


Background: About a half of life time cases of mental disorders start by 14 years of age. First sign of mental illness or emotional distress can emerge in school environment. So schools are to be viewed as the potential place for recognition of mental health problems, but an unexplored area. This study describes the working of a new model for district adolescent school mental health programme, UNARV in Kerala. Methods: A descriptive study of adolescents referred from schools, seen at UNARV clinic over a period of 5 years (2007–2012). Study sample consisted of students with behavioral and scholastic problems who were referred by trained teachers from Government and Government aided High School (8th to 10th class) and Higher Secondary School (11th and 12th class) under aegis of District Panchayath, Thiruvananthapuram, Kerala. They were evaluated and given psychosocial and pharmacological interventions by child mental health expert. Results: Total 2432 students attended UNARV clinic during the period. Most common problems observed were involvement in physical fights (38.3%), viewing and showing pornography to others (21.8%), poor scholastic performance (20.7%), skipping classes (19.1%), alcohol abuse (19%), smoking (14.2%), and engaging in love affair (8.5%). Common mental disorder diagnosed was conduct disorder (36.4%). UNARV helped in reintegration of such students back in to schools and stalled the trend of such students from being dismissed or suspended from class. Conclusion: UNARV forms a sustainable alternative district model in a resource poor environment. School teachers were trained as primary counselors and expert intervention was ensured.

Keywords: adolescents, adolescent mental health, UNARV, adolescent mental disorders, school mental health


How to cite this article:
Jayaprakash R, Sharija S. UNARV: A district model for adolescent school mental health programme in Kerala, India. Indian J Soc Psychiatry 2017;33:233-9

How to cite this URL:
Jayaprakash R, Sharija S. UNARV: A district model for adolescent school mental health programme in Kerala, India. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Oct 19];33:233-9. Available from: http://www.indjsp.org/text.asp?2017/33/3/233/214591




  Introduction Top


Adolescence is a transitional stage in human development during which the individual undergoes marked physiological, psychological, and social change in the process of growing from child to an adult. Community-based studies show that up to 20% of children and adolescents suffer from a disabling mental illness.[1],[2],[3] Indian prevalence is 12.8%.[4] Kessler et al.[5] (2005) reported that half of all lifetime cases of mental disorders start by age 14 years. Presence of mental illness in children and adolescents, if not properly diagnosed and treated, increases the likelihood of significant health issues for them as adults and greatly limits their ability to become productive members of society.[6] But worldwide child and adolescent mental health service availability is very rudimentary and many lack any policy.[7] Situation in India is almost the same. It is mainly a city based Out-Patient service and a costly affair. The first sign of adolescent mental illness or emotional distress can emerge in a school environment. It is well known that mental health issues such as anxiety, depression, and family problems are often the root causes of poor academic performance, disciplinary issues, and truancy.[8] WHO opined that schools are to be viewed as a potential resource for the recognition of children and adolescents in need of formal diagnosis and treatment.[9] The school-based model is potentially more flexible and can be implemented more easily in resource poor areas. But school-based consultation services model are not well developed across the world. This gap leads to failure to reach out to children who otherwise need help to avoid many of the problems associated with school dropout and other negative consequences due to mental health problems. So if the teachers are provided with sensitization training to understand adolescent development, adolescent developmental challenges, mental health problems and disorders, and primary skills in proactive adolescent counseling, they can do the early identification and primary intervention in the school campus itself. Even though there is 100% school enrolment in Kerala, there is no system to address the developmental and behavioral issues of adolescents in the school environment. Considering this gap, the aim of the present study was to describe the working of a new model for district adolescent school mental health programme, UNARV in Kerala, over a period of 5 years from 2007 to 2012.


  Methods Top


Study design: this is a retrospective record-based descriptive study. It aims at setting up of new district level adolescent school mental health programme and describes the profile of students who took treatment from the UNARV clinic over a 5-year period from 2007 to 2012.

Study setting: Kerala is the southernmost part of India and Thiruvananthapuram is its capital city. Students of the Government and Government aided School belong to lower socioeconomic class and lower strata of middle socioeconomic class. Majority of the population earns their livelihood by manual labor or works in private institutions. A small segment of population works in lower rungs or clerical posts of government service. Thiruvananthapuram has a district hospital and a Government Medical College hospital. But adolescent mental health service is more or less confined to the department of Psychiatry and Behavioral Pediatrics Unit under department of Pediatrics of Medical College.

The study setting was UNARV clinic, which was set up in 2007–2008 in the office building of District Panchayath, Thiruvananthapuram, Kerala. It was set up in district panchayath premise to avoid the atmosphere of a mental hospital and related social stigma. UNARV is still being successfully continued.

Inclusion criteria: all students of Government and Government aided high school (8th to 10th class) and higher secondary school (11th and 12th class) under District Panchayath, Thiruvananthapuram, Kerala, who were referred to UNARV for behavioral and scholastic problems by primary counselors, were included in to the study population.

Exclusion criteria: students from below eighth standard, students from private schools, and students from other districts of Kerala were excluded from the study population.

Tools: a prepared intake proforma was used for detailed evaluation of each child referred to UNARV clinic. International Classification of Disease-10 Classification of Mental and behavioral disorders – Diagnostic Criteria for Research (ICD-10 DCR)[10] was used to diagnose child mental health disorder.

Procedure: the important steps in procedure are described in the flow [Figure 1].
Figure 1: Shows the functioning of UNARV programme. UNARV involved three levels of service delivery namely school level training awareness for Principals/teachers/students-primary counselor, district UNARV clinic and Web assistance and Pediatric department of Government Medical College Hospital.

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A total of 78 high schools and 55 higher secondary schools participated in the process. The first step was selection of two teachers each from Government and Government-aided High school and Higher Secondary Schools under District Panchayath, Thiruvananthapuram, Kerala. A total of 78 high schools and 55 higher secondary schools participated in the process.

Two workshops of two days duration each were conducted for these selected teachers during every academic year and they were designated as primary counselors. At the outset the aims and objectives of the project and responsibilities of the participants were explained in detail to them. The topics in the training workshop included adolescent developmental psychology, developmental challenges, development of life skills, scientific teaching-learning methodology for teachers, a brief overview on the mental health problems and disorders including conduct disorder, learning disability, scholastic backwardness, examination fear, school dropout, adolescent depression and suicide, sexual abuse, smoking, alcohol and drug abuse, involvement in love affair, masturbation, new generation issues like, abuse of mobile phone, internet, visual media, and emerging new issues if any. The child and adolescent mental health experts were the resource persons for the workshop.

Students with scholastic backwardness, behavioral problems, smoking, alcohol and other substance use, involvement in love affair, examination fear, and other similar concerns were referred to respective primary counselor (trained teachers) by other teachers in the school. For strengthening this referral system one day sensitization workshops were conducted every year at various levels, with the active participation of the headmaster/principal, all class teachers, parent teachers association, and mother parent teachers association, and other school teachers. In the meeting, teachers were asked to refer the student with problem behavior to the respective trained primary counselors.

Each student so referred with problem behavior was evaluated by the primary counselor by using a prepared intake proforma. The students were given primary counseling at the school level itself. As part of primary intervention, the parents of the children with problems were summoned to school and sessions on the state of the child and psycho education were held by the primary counselor. Issues like scheduling of learning activity, creating a child-friendly learning atmosphere, and similar issues were discussed. Students were reviewed weekly by the primary counselor. Those students with no satisfactory improvement after a reasonable period were referred to UNARV clinic. The primary counselors were given instructions to register the names of the referred students with District Panchayath office, through telephone of the office or officer in charge. An officer in the District Panchayath was placed in charge of a point person to register the names of the referred students and coordinate the whole office activity. The officer in charge was not involved in the clinical management of the student in the UNARV clinic. UNARV clinic was conducted by the child mental health expert in a specially designed room where clinical confidentiality could be maintained professionally.

In the UNARV clinic, a child and adolescent psychiatrist's service was provided on a voluntary basis. It runs on every Tuesday from 2 pm onwards till evening. The expert evaluated the students and their families. The economic class of the family was labeled as Above Poverty Line (APL) or Below Poverty Line based on the specification given by the local self-government institutions in the ration card of respective family. History of family psychopathology was noted during the detailed interview with the parents. The clinical diagnosis was done as per ICD 10 DCR guidelines. They were provided with psychosocial interventions like cognitive behavioral therapy, cognitive problem solving skill therapy, and so on. The parents were given family therapy for issues of alcoholism, quarrelsome, and domestic violence. Parent management therapy was given for families of children with conduct disorder. Pharmacological interventions were also added in indicated cases. Drugs were prescribed for depression, acute psychosis, bipolar disorder, severe aggression, severe anxiety, and so on. They were reviewed every month as a routine. Acute cases were reviewed every week. From UNARV clinic a confidential note was sent back to the primary counselor regarding the condition of the student with suggestions regarding the monitoring of the children in the school and the need for sending them back on the review date.

The children who did not improve or who needed detailed evaluation were referred to Behavioral Pediatrics Unit, which is an exclusive child and adolescent mental health service center under department of Pediatrics, SAT Hospital, Government Medical College, Thiruvananthapuram. All the children were subsequently followed up in UNARV clinic.

A website was also designed in the 2012–2013 academic year so that primary counselor could post questions to the child mental health expert. A specific pass word and user id was also given to the primary counselor in each school. The expert answered them once in a week.


  Results Top


The total number of adolescents who were referred to and attended the UNARV clinic during the period was 2432, See [Table 1]. Boys dominated in the UNARV sample (63.4%). Majority of students (55%) belonged to middle adolescent category in the age group of 15–16 years. In the assessed population, 64.8% belonged to APL family. History of family psychopathology was present among 48.7% of the sample. The main family psychopathology noticed alcoholism (23.1%), quarrelsome family (17.3%), domestic violence (14.9%), and families abandoned by father (11.3%) see [Figure 2].
Table 1: Basic data among the UNARV sample (n = 2432 )

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Figure 2: Profile of family psychopathology among the UNARV population (n = 2432)

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The most common three problems noticed in these children among the UNARV sample were involvement in physical fights (38.3%), viewing and transmitting pornography (21.8%), and poor scholastic performance (20.7%), see [Table 2]. Other problems noticed were given in the [Table 2].
Table 2: Common problems for which referral was made to UNARV (n = 2432)

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The most common three diagnoses made were conduct disorder (36.4%), specific learning disability (9%), and depression (5.8%), see [Table 3]. Other problems noticed were given in the table. Adolescent developmental challenges were present among 19.7%, see [Figure 3] also.
Table 3: Diagnostic profile of adolescent mental disorders seen among at District level UNARV clinic population (n = 2432)

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Figure 3 Profile of adolescent developmental challenges among UNARV population (n = 2432)

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  Discussion Top


Predominance of the boys in the UNARV sample could be due to the fact that the majority of the school population referred had behavioral disorders; behavioral disorders being more common among boys, see [Table 2] and [Table 3]. Among the UNARV population 55% belonged to the middle adolescent group, see [Table 1]. The adolescents in the middle stage usually have to face more developmental challenges.[11]

As mentioned earlier, majority of the UNARV population belonged to APL class [Table 1]. The awareness about adolescent mental disorders and its implications are more among the middle class population. So the service utilization was more among them. The high prevalence of family psycho pathology influenced the behavior formation and development of mental health disorders among children as evidenced in the UNARV sample. The families abandoned by father face scarcity of money for sustenance of life on day to day basis. Witnessing domestic violence produced a negative impact on the children of such families. The environmental factors also play a significant role in the causation of mental health disorders among children and adolescents.[12]

The common problems for which the students were referred by the primary counselor to UNARV [Table 2] were involvement in physical fights, viewing and transmitting pornography in groups during school hours, poor scholastic performance, skipping classes, alcohol abuse, smoking, and engaging in love affair. Viewing and transmitting pornography, alcohol abuse, and smoking are exponentially increasing among the adolescents and preadolescents. This could be due to the impact of globalization among all conservative societies and cultures across the globe. Students who skipped the classes returned home in the evening. The parents were not aware of this skipping of classes. The students who absconded from the school had not returned back to family or school. They had gone with the peer group. In absconding either school teachers or parents would search and find out them after they were missed for days or weeks. In certain situations police cases were registered and they had helped. All the listed problems were more among boys, except engaging in love affair, sexual abuse (victim), and deliberate self-harm, which were more among the girls. In a conservative society in which there is a moratorium for emotional intimacy and engaging in love affair among students, even though it is a natural phenomenon among adolescents. Once they start to engage in love affair, their learning activity and scholastic achievement may decline, as their energy and time gets otherwise channelized. This was the key problem and concern of parents and teachers. Teachers have observed or the parents have complained about their ward to the school authority of love affairs taking place in and out the school premises. Such wards were seen by primary counselor and referred to UNARV clinic for professional management and ‘breaking’ of love affair. Both girls and boys were subjected to sexual abuse. But all the sexual perpetrators were boys. Cases of sexual abuse (both victim and perpetrator) were referred to UNARV clinic for psychosocial intervention. By this time all the legal formalities were completed. In needy situations, the students (abuse victims) from the UNARV clinic were referred to Gynecology department of Government Medical College, Thiruvananthapuram for completing the routine medical and legal procedure. Apart from sexual abuse, mutual sexual advancements were noticed among the boys (1.8%) and girls (2%) during love affair. Here, there was no forceful abuse. In mutual sexual advancement, both partners were minors. But dating type of sexual behavior was not observed in the UNARV sample. Whether mutual sexual advancement is becoming a new trend among the adolescent lovers in an otherwise conservative Indian society needs to be probed further in detail. Regarding deliberate self-harm, the impulsive and aggressive behavior was born out of anger and other relational and emotional issues in the family, among peers and one's own emotional domain. It happened in both school and family atmosphere.

The common adolescent mental disorder noted was conduct disorder (36.4%) [Table 3]. Generally conduct disordered children are subjected to all kinds of punishments including severe corporal one in family and school, especially in the Indian scenario. The parents, family, and teachers coming in proximity with these children are also under stress and anxiety. Usually such children are labeled as ‘problem child’ in family, school, peer group, and social atmosphere. Sometimes they will be sent out from school or they are more likely to be rejected by his or her classmates[13] and this peer rejection can place the child at risk of school truancy and for associating with other antisocial and aggressive peers.[14] Apart from this, up to 40% of rejected children were aggressive, and children who are aggressive and rejected have been shown to be at the highest risk to develop antisocial behavior in adolescence.[15] A coercive vicious cycle can be observed here.[16] The behavioral problems among the students has created problems in the class, peer group, and school atmosphere. So they were picked up by the primary counselor and if no improvement occurred by primary intervention, they were referred to UNARV.

Conduct disorder was more among the boys than girls (3.9:1) [Table 3]. It is a male dominated disorder.[17],[18] Among them, 55% were adolescent onset type of conduct disorder with gang behavior and socialized aggression. But in the Sarkel et al.[18] study the predominant group comprised of the child hood onset type (73%). It could be due to the difference in the sample population. The most common five symptoms noticed among the conduct disordered children in the present study were ‘frequently initiates physical fights’ (91.7%), ‘frequently bullies others’ (90.01%), stealing (88.3%), ‘frequently truant from school’ (76.7%), and ‘deliberately destroys the property of others’ (66.7%). As mentioned earlier, environmental factors such as family environment played a major role in the behavior formation of child [See [Table 1]. Problems in the child rearing practices such as poor parental supervision, harsh discipline, broken family, single parent, physical and sexual abuse, poverty, alcohol, and violent behavior of the parent also produce mal adaptive behavior in children and adolescents.[19],[20]

As mentioned earlier, usually the students with this kind of behavior problem are dismissed or suspended from the school. But the UNARV could put a stop to this trend. In the High School and Higher Secondary Schools under the District Panchayath, Thiruvananthapuram the students with problem behavior are now being referred to UNARV after primary intervention without summarily dismissing them or suspending from school at the outset. As mentioned earlier, in the UNARV students with conduct disorder were given cognitive behavioral therapy, cognitive problem solving skill therapy, and anger-control management. Their parents were also given family therapy and parent management training.

Among the UNARV sample 26% received medication. The commonly used drugs were risperidone, fluoxetine, escitalopram, sodium valproate, and clonazepam. The follow-up rate was 85% in the UNARV clinic. Among the UNARV sample 95% returned back to school.

Adolescent developmental challenges that were present in 19.7% of the UNARV sample [Figure 3]. It was solved with psychosocial interventions. Anger management and life skill approaches were discussed during the interactive sessions with students in each school. Many questions were asked by the adolescents to child psychiatrist during these sessions at various schools. The questions included the developmental challenges, which they faced in different spheres.

Thus, the UNARV model became an effective measure of intervention for addressing the adolescent developmental challenges, mental health problems, and disorder at the school level itself. It successfully helped to fill the gap between the community need and existing system of interventions. It also addressed the poor availability manpower with accessibility of child and adolescent psychiatrist and avoided social stigma. Social stigma was minimized by involvement of teachers as the primary counselor, managing them primarily in the school itself, and starting the UNARV clinic in the District Panchayath premises, thus, avoiding the mental hospital environment. In conclusion, it emerged as a sustainable and alternative model in a resource poor environment, at district level. Two most important factors that made the UNARV acceptable and sustainable were the role of school teacher as the primary counselor and availability of an expert at secondary level intervention center outside the school campus. The cooperation from school teachers was very good and they formed forms the main pillar and this helped in the success of the project. The attitude and cooperation from the officials in charge of Panchayath office were also excellent. They carried out the establishment needs of UNARV clinic in a very cordial manner without intruding in to the clinical management or privacy and confidentiality of each student. They did not even try to see the student or their parents in the UNARV clinic. So any district level local self-government could take initiatives of this manner.

The web site helped the primary counselor to get an swers quickly, handle the students effectively and keep in touch with the expert and get opinion on a day to day basis. Hence, it is felt that UNARV model can, therefore, be replicated and disseminated to larger geographical area even at state or nationwide.

To conclude, the present model UNARV ensured three levels of care namely primary counseling by trained teachers, expert intervention at UNARV clinic, and tertiary care at hospital level if and when required. There were many draw backs in the other existing models. In many of the existing school mental health models, only a counselor will be available in the school. The school teachers were not trained, taken in to confidence or made to involve in intervention. There is no consultation-liaison work between teachers and counselor in the school. Also expert interventions were not ensured as a part of these models. These issues are effectively circumvented in the UNARV model.

Advantages of UNARV

  1. The poor sensitivity of the school education system about developmental psychology of adolescents and the unique behavior of adolescents were addressed in UNARV.
  2. Inadequacy of the service delivery system in identification and intervention of developmental, behavioral, and emotional disorders of adolescents at school level itself was addressed by a sustainable system, mainly with primary and secondary intervention.
  3. The barriers to service utilization and social stigma were minimized by involvement of teachers as the primary counselor, managing them in the school itself and starting the UNARV clinic in the District Panchayath premise, thus, by avoiding the mental hospital environment. It increased the acceptance of the model and ensured accessibility, availability, and privacy to the students and their parents.
  4. Expert intervention was also assured.
  5. Web-based addressing the new emerging issues and answering of queries by the expert had made the initiative more vibrant and helpful to the primary counselors.


Recommendations

The UNARV can be replicated in other parts of the country and other similar resource deprived countries especially with scarcity of child and adolescent mental health professionals.


  Acknowledgement Top


To the children, parents and teachers, who are the back bone of this project and without whom this would not have been successful.

Financial support and sponsorship

Nil.

Conflicts of interest

We hereby declare that this project is funded by Thiruvananthapuram district panchayat, under decentralized planned from 2007 to 2008 financial year onwards, where we gave the expertise and voluntary service.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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