Mental healthcare for children during Covid-19 in India
This article is part of a feature series exploring how the Covid-19 pandemic and the measures to prevent its spread are impacting the human rights of under-18s.
This interview has been edited for length.
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[DELHI, 15 September 2020] In a country that spends less than one percent of its health budget on mental health care, to what extent has the Covid-19 pandemic affected people’s mental health? Some preliminary studies already show that stress, anxiety, loneliness, isolation, sleep disorders and depression are all symptoms of the pandemic and lockdowns, while others show that the psychological impact is greater for certain groups, including young people. To find out more about the impact on under-18s and how mental health support is delivered during a pandemic, CRIN spoke with Dr. Kavita Mangnani, clinical psychologist and Director of the restorative care programme at HAQ-Centre for Child Rights in Delhi.
To begin, can you tell us a bit about HAQ’s counselling services? Who are the children you support and what does it consist of?
At present we are mostly working with children who have been sexually abused, who are in need of care and protection. We assist these children with medical needs, counselling and psychological support. We also provide lawyers to the children who want to fight their case in the court. We also provide counselling to the families to deal with the trauma and counselling to the children and parents together to improve the relationship, if the need arises.
Generally the process for counselling is: we call families to HAQ’s office because it’s a neutral space, but if they’re unable to come then we do make home visits to assess the situation and for initial rapport building. We see what their environment is at home and, if need be, we also include the parents in the counselling session. When family and child cannot come for regular counselling, it becomes difficult because in our country it is still not a very accepted mode of help. You struggle to make the parents understand how counselling will benefit their children and the parents too.We also provide counselling for children in conflict with the law, for whom we go to the Juvenile Justice Board, where its Principal Magistrate refers the child to us if they feel the child should be provided counselling. For other children, such as children who are in need of care and protection or are victims of abuse, we receive referrals from different agencies like NGOs, schools, child welfare committees, the Delhi Commission for Protection of Child Rights (DCPCR) and sometimes parents, too.
Counselling brings to mind a picture of two people in a room, the client and the counsellor, and a question-and-answer dynamic. Is this true to life or is counselling broader than this?
It’s much broader. The general perception is that counselling is just talking, with the counsellor in an authoritative position. But counselling is much more about helping the client understand the issues, the underlying issues. What we see in people’s overt or observable behaviour is just the surface. For children who’ve been sexually abused, we try to make them understand that it’s not their fault. Sometimes they feel guilty and blame themselves. Their self-esteem, body image and self-confidence really shrinks. It affects their academics and inter-personal and social relationships. So we work on all those aspects. Another thing is to make the client independent of the counsellor and build psychological resilience in the child. We help to build their coping mechanisms, help them to recognise the resources they have and how to effectively utilise them. That’s the objective of counselling.
In your experience as a counsellor, what impact has the pandemic had on children’s mental health?
When lockdown was announced we got in touch with families that we were supporting. The first thing we did was start calling everyone. We made it mandatory that every family should be contacted at least once a week to find out if they’re okay, if they need any support. Most of these families are from a very poor socio-economic background. A lot of them couldn’t provide basic necessities to the children like milk and bread. This was making both adults and children very anxious and depressed. Schools were closed, so the meal that children used to get there is now missed. On a physical level, we know children have been losing weight. Their stomachs were full when they were going to school. But since the schools were also closed it affected the physical health of the children.
On a mental health level, I found that children as young as six years old were easily getting angry, irritated, frustrated and would start crying sometimes for no visible reason. They would fight with their siblings. They would become more clingy to their parents. Some children also shared that they were really lonely at home and wanted to go out. There was this one child who was only seven years old who said: “I don’t know what to do. I feel really lonely,” and you could sense in his voice that the mere act of talking was laborious for him. I spoke to him multiple times. We also started a helpline during the pandemic. We collaborated with the Delhi Commission for the Protection of Child Rights (DCPCR). Four of us from the team volunteered for the helpline. And within the span of one month, we received around 250 calls in total from all age groups.
Do you think the news coverage has had an impact on children’s mental health?
Yes. People were glued to the news. It put a lot of fear in children, especially younger children. I actually had to tell every parent I spoke with to please stop discussing the virus, that there is other news too. All they see are the increases in cases, the spikes, but less about the people who recover.
I also observed that in very young children there was prejudice against people who cannot afford to buy masks or hand sanitisers. This was alarming for me, to have this kind of attitude towards anyone. Some of these prejudices are rigid, so we try to make them understand that it’s not one person or one community’s fault. So ‘othering’ has started. It’s not a healthy attitude.
Have you seen any changes since the pandemic started in terms of the number of children seeking support and the symptoms displayed compared to before the pandemic?
There was a spike in cases we received, especially about physical abuse, concerning parents who lash out their anger and insecurities on their children. This happened even in families in which I had never heard of instances of the children being hit, or the father beating the wife. When the lockdown was slightly relaxed in June, we received around 40 cases of sexual abuse within a month, compared to the 10 cases we received during the complete lockdown phase.
Where there was already violence in the family, it further increased because now women cannot just leave the house. They have to stay in the house and face the violence. And there was nowhere to go because everything had shut.
Have you seen an increase in the medicalisation of children during the pandemic because of mental health issues?
From what I saw, during lockdown there was little access to medication anyway. In the first phase of lockdown there was still a lot of concern that anyone could be infected so people were avoiding going to hospital or clinics. And no pharmacy would give you medication for any mental health issue without a prescription. But I feel that medication often just treats symptoms. They don’t change your thinking patterns. It can of course help with symptoms, but it’s better to try alternative therapies first, like counselling or other psychological therapies. In extreme cases where a person has, for example, suicidal tendencies, then of course I would refer that person to a psychiatrist. But for people who are feeling low, medication won’t help them understand why they’re feeling low. And medication alone cannot be the solution.
Are there groups of children that are disproportionately affected by the mental health impact of Covid-19? And what needs to happen to improve the situation?
Access to mental health services was affected especially for children in conflict with the law because everything was shut. The courts and the Juvenile Justice Board are still closed, so we’re unable to get access to the children. When we tried calling some child care institutions they told us the children are fine, that physically there’s no issue. Very few of these institutions allowed us to talk to children on the phone. I don’t know if they understand that mental health issues can be a concern. These children have no connection with the outside world. Also particularly affected are children who don’t have access to a phone, such as those from marginalised groups like migrant children. Some children we were in contact with before, who moved to their home villages, we lost contact with them.
What are the systemic problems when it comes to providing and accessing mental health support in India?
Education on mental health is a big issue. In India there are still a lot of myths about mental health support. It’s seen as very shameful to have any sort of mental health problems because of perceptions of being ‘mad’ and because of stigma. It’s the attitude, too, that we don’t have to get mental health support, that we can manage on our own. Regarding children, it’s very difficult for parents to understand that their children can have a mental health issue, which they often see as just attention-seeking behaviour. It’s hard to get parents to understand that children can feel sad or anxious, especially since children do not have the language to articulate their feelings.
In my experience, when I started working as a counsellor, people would look at me as if to say ‘why do you even want to talk to my child?’ There was no understanding of what a counsellor is or the subject of psychology. Some people thought because I studied psychology that I could read their minds. Even today in India if there is a psychiatric illness, people would rather go to a traditional healer because they think that some evil has possessed the body. These ideas are still prevalent. In terms of provision, we have very few professionals who provide counselling or mental health support. Sometimes there’s one counsellor for many children, and sometimes they’re not even professionals. And in terms of funding, there is very little for mental health services.
Why is mental health support for under-18s important?
In childhood it’s when we are forming our own perceptions of the world around us and defining our own identity, and any kind or trauma or abuse during this time can have a long-lasting impact. This will impact all relationships in the future. The children I work with, some of then said that they are bad children because they had been abused. And if these children don’t receive psychological support during the early phase, then those perceptions set in, and it becomes more rigid with time. A child’s mind is more flexible, they are more open to other ideas. Once they grow up, there’s more rigidity. It’s harder to break thought patterns. That’s why early intervention is so important.
What needs to change in order to improve mental healthcare in India?
Since we’ve had the Mental Health Care Act 2016, more professions now have recognition as qualified to treat mental health issues, including counsellors, clinical psychologists and special educators, but this needs to be recognised at state level and there should be effective implementation of the Act. There should be more funding. There are very places that provide or focus on early intervention.
Government services are mostly limited to psychiatric help only. But it’s important that the government appoint more counsellors and other mental health professionals such as psychiatric social support workers, psychologists, etc.
In the hospital where I used to work, there were only two psychologists, no counsellor and one psychiatric social worker for an outpatient department treating approximately 400 patients a day. So you can imagine! Usually at the most you can see 7-8 clients in a day, with 45 minutes to one hour given to each person, but in these circumstances it’s just not possible. You see one client for one minute. So it’s important that the government should make mental health services accessible to more people at affordable prices and work towards eliminating the stigma around mental health problems.
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