Mental health matters too!

24 World Health • 46th Yem, No: 6, November-December 1993 Mental health matters too! Anula D. Nikapota A child who is healthy is physically well and also happy, growing and developing well according to his or her age. The child mental health programme in Sri Lanka encourages health workers to watch for families and children under stress. P rogrammes for child and family health have for several years included specific tasks and training related to child development and me11tal health. Identifying the problems in this field led to the realization that promoting child development needs not one but many different inputs and the use of several different strategies. The child mental health programme in Sri Lanka is implemented by the Family Health Bureau in the Ministry of Health, with the support of UNICEF. Coordination with other relevant agencies, particularly the training institutions for primary health care, has helped to nurture and extend these new inputs. One early innovation was to introduce the concept of the integrated nature of health, growth and development. In other words, a child who is healthy is physically well and also happy, growing and developing well according to his or her age. One strategy selected was to include in the growth chart of each child a few selected developmental milestones such as walking, talking and understanding simple requests. This A happy child is more likely to show normal growth and development. served to create awareness of this concept among parents, families, communities and health workers. Health workers were taught about children ' s developmental needs and about ways of discussing with parents how to promote development by fulfilling those needs. For example, one young mother who was very poor and had two young children was upset because she could not provide the kind of toys that would help her child to learn; she had read that this was important. Health workers routinely visit homes with young children, and her own health worker had established a good relationship with her and presently learnt about her worries. The health worker was then able to build up the mother's confidence in her own ability to help her children's develoement through play and learning during day-to-day activities, using ordinary objects for play. Another aspect of the programme of particular value in certain areas World Health • 46th Year, No. 6, November-December 1993 involves identifying children who are slow developers, are under acute stress or have behavioural problems. Some of these inputs are similar to those in other parts of the world. Risk factors at home A unique feature of the programme is the introduction of the concept of routinely monitoring the home environment for risk factors . Such risk factors were identified during research which in fact used the health workers as research assistants. This part of the programme is still regarded as more of a project, although it has been accepted for use nationally. The purpose of this monitoring is not merely to identify family problems. The real reason for this approach is that there are always families where educating them or "telling them what to do" is not sufficient because - for a variety of reasons - they find child care stressful or more than they can easily cope with. This is a common experience in health-related field work in many cultural settings. Working with such families- that is, helping families to improve their mental health and functioning so as to cope and care better for their child - is very much part of clinical practice for child and family mental health. So it seemed entirely appropriate to introduce a similar concept into the primary health care programme for child and family health. The risk factors include those that are likely to be associated with child care problems such as a very young mother, poor spacing (more than two children under 3 years old), lack of interest in the child, or a mother who finds understanding health messages difficult. In addition, there may be evidence of poor coping from whatever reason, such as poor organization in the home, or of specific problems such as severe marital discord, mental illness in parents, alcoholism and drug abuse, abject poverty, or trauma due to the conflict situation in the country. Sadly, the last factor is all too predominant in some communities at present. Health promotive behaviour Training materials have been developed which emphasize the basic principle of working with these families, which is for the health worker to approach the issue of meeting children's needs by looking at the families' problems, as well as their resources, and working with them to achieve, step by step, health promotive behaviours in their daily life. A mother was unhappy and resentful that her husband was drinking heavily. The couple quarrelled every day and the children became increasingly worried by this. The mother told the health worker, who had known the family since the Playing is/earning. The toys don't have la be expensive Bothtime. 25 youngest child was born and who was aware that the family had durable strengths: the husband did care for the family, and the couple did care for each other. She explained to the wife how she could use those strengths by perhaps being less irritable with her husband even when she might feel he had let her down. The health worker also got on well with the husband and so was able to talk to him about his hopes for the children - at the same time using this opportunity to point out that his drinking was upsetting the children. Gradually the situation did improve, and the health worker went out of her way to praise all the family for their efforts. Any programme has to be evaluated to judge whether its efforts are really leading to improvement. In the case of this programme in Sri Lanka, such tasks as are described here are still not as familiar - and hence are not performed as extensively in the field- as are tasks related to immunization or nutrition, for example. Those concerned with the programme, however, feel that these inputs, and particularly work with families and children under stress or having problems in coping, will significantly enhance child and family health. • Or Anula D. Nikapota is a consultant in Child and Adolescent Psychiatry at the Brixlon Child Guidance Clinic, 19 Brixton Water Lane, London SW2 I NU, England She has also worked as a UNICEF consultant with the child mental health programme in Sri Lanka.