Dr Manju Antil (Counselling Psychologist and Psychotherapist)

The schools can help a lot by helping in the early identification of students with mental health problems, by keeping track of the student's overall performance in school, and if they notice any changes, they can inform the parents. They can also encourage the parents to share any changes in the student’s health or situation so that early identification is possible.

The teacher can observe the following signs for early identification:

• The drastic decline in the marks of the student.
• Taking frequent leaves from school or long-term absenteeism.
• Lack of focus on daily activities and classroom work.
• Sudden changes in behaviour like anger issues or fighting with the other children very often.
• Fatigue over a long period.
• Significant changes in play behaviour or taking too few changes in play activities.
• Generally feeling irritated or frequent mood swings, the child.
• Withdrawal from friends and wanting to be alone during the lunch break or other school activities.
• Less participation in activities.
• Each student will have different symptoms, so the teacher needs to keep track of the changes in the behaviour. If the teacher feels that a student might be having some mental health issues, then he/she can refer the child to the school counsellor or professional counselling services, who could, in turn, refer him to the relevant expert.
• The schools may take the following steps for students with mental illness:

Attendance:

• The school can have flexible school hours, or a special timetable can be made according to the child's needs.
• Some flexibility may be given for attendance and punctuality.
• A safe and quiet place can be provided for taking a rest or a break when the student feels over-agitated or restless.
• School staff may accompany the child to the resting place when needed.

Classroom management:

• Seating arrangements can be made according to the comfort of the child. For example, sitting next to their friend.
• Teaching should be clear and flow so the student knows what to expect next.
• Frequent positive feedback and encouragement should be given from time to time. This would help all children.
• They should be allowed to participate in classroom activities of their choice. Nothing should be forced upon them.
• If there is a history of suicidal behaviour, keep the child on watch.

Self-management for daily tasks:

• The students may be assisted while recording homework.
• They can use folders and files to organize notes.
• They can use a calendar to mark deadlines or submission dates of assignments, so they do not forget. They may also use a reminder on their phone.
• They can also use sticky notes to remember important things. They can put it on their desk, school diary, etc.
• The teacher may remind the child while transitioning from one lesson to another to prepare themselves for the next lesson.
• The teacher may also remind the child to check the books and notebooks that must be taken home for homework.

Lunch Break arrangements :

• The teacher should pay special attention to the child’s behaviour during the lunch break.
• They can be attached to a ‘buddy’ with whom they are comfortable and who can give company to the child to avoid isolation.
• The teacher can suggest or help them actively find their leisure time.
• Extra Curricular Activities:
• Simple tasks like organizing books, arranging bulletin boards, etc., may be given to help them to gain a sense of competence and self-worth and to boost their confidence.
• They should be allowed to participate in extracurricular activities of their choice according to their comfort.

Communication with teachers:

• The teacher can reach out to the students to build a good rapport and a healthy relationship.
• The student’s progress should be recognized, and they should be motivated very often.
• The teacher should accept the student’s difficulties and feelings caused by their health conditions.
• The teacher should avoid criticizing the students.
• The teacher should encourage the child to express and share their feelings openly. The teacher may reflect upon later on what they have shared.
• The teacher should remain objective, and they should not judge the child based on any subjective biases like caste, class, gender, religion, disability, etc.
• The teacher can also encourage the child to seek professional help from a counsellor.
• A Buddy system can be done. The student with a mental illness may be paired with a self-confident and helpful student to support the child emotionally.
• Mutual support and acceptance of the child among peers should be encouraged to help the child build a social circle.
• The teacher may observe interactions with other children and offer help and guidance on improving the child's social skills.
• The teacher should share things with the school administration and parents about the Child's behaviour with the consent of the child/parents if possible.
• The teacher should not be judgmental about students' behavioural issues, e.g., whether they are good or bad 

Classroom interaction:

• The teacher should use different teaching strategies to make learning more interesting for the students. Interactive sessions and practical experiences may also be planned so that the students are actively involved in the classroom.
• The teacher may provide the learning materials in advance; for example, the critical points of the next chapter can be given in advance so that the child knows what is coming next.
• The teacher can give written notes to the child to decrease the stress on memory, attention, and organization.
• Graphic organizers or essay writing frameworks may be used to help the students organize information efficiently.
•  Short breaks may be given during the lessons to avoid stress.
• The teacher can prepare worksheets and other teaching materials according to the child's needs.
• Mnemonics, mind maps, and other organizational skills can be taught to the child to understand concepts better.
• Instructions used in the classroom should be simple and short. Instructions should be given slowly and may be repeated whenever needed by using oral or visual prompts.
• Teaching accommodations such as adjusting the content's difficulty level or changing the teaching order can be made.
• Additional learning tools such as recorders and timers should be allowed by the school.

Classwork:

• The tasks given should be broken into smaller units.
• Task initiation may be facilitated by giving demonstrations or guidance.
• Additional hints or prompts like a reference to a particular book, chapter, section, etc., may be given to encourage and help the students.
• The students should be encouraged to develop good time management skills to manage their time correctly.
• Single-sided notes and worksheets should be given so that it is easy for the student to make notes along with the worksheet.

Questioning:

• Short answer questions like true/false, fill in the blanks, multiple choice questions, etc., can be used for the comfort of the child in case of disabling mental health conditions...
• The students should be notified well in advance about the upcoming tests or exams so they have enough time to prepare. Surprise tests, etc., should be avoided as it creates a sudden situation of panic, which affects the child's mental health.
• In the class, non-verbal responses like nodding the head, pointing the answer on the blackboard, etc., should be allowed.
• When questions are orally asked in the class, ample time should be given to answer so the student can process the question.
• Sufficient instructions or options should be given to help them to respond

Group discussion:

• The students can be grouped according to their comfort level.
•  The student’s participation in the group discussion may be facilitated based on their abilities and interests 

Assignments:

• Short assignments can be given so that it is not too much of a burden for the child.
• A choice of topics may be given so the students can choose their assignments.
• A framework with keywords or how to write the assignments can be helpful for the child.

Homework:

• Homework given should be of a minimum level suited to the child's learning needs to reduce the student's burden.
• Flexible submission dates suitable for all may be given. The deadline may be extended if the child has genuine reasons for not submitting the work on time.
• The difficulty level of the homework can be adjusted according to the needs and situations of the child.
•  Diverse submission formats like oral presentations instead of written ones or vice versa may be used according to the child's convenience.
•  The teacher may also email the homework to the parents or guardians, and written instructions can be given instead of oral ones so the students can refer back to them at home

Examination:

• Compensatory time may be provided so that the student can complete the exam and they do not panic. 
• Special seating arrangements or unique examination rooms may be provided for the child.
• The invigilator can remind the student to focus on answering the exam as they may tend to divert.
• Any other special exam accommodation may be given if the child's mental health professional is advised.
• Realistic expectations should be set about the child's performance so they do not feel discouraged or sad later at the time of results. 
• The teacher should not cut marks for non-academic reasons like poor handwriting, as it can demotivate the child.
• The teacher may provide important sections in textbooks to guide their exam preparation and to reduce exam-related stress. If possible, sample tests and exams may be given as a practice for children with a mental illness.
• The child may be allowed to eat and drink during the tests and exams if needed.
• Students with anxiety disorder may feel very anxious during exams. A scary environment should not be created before exams in the classroom, and the parents should also be encouraged to be as normal as possible at home.

Individualized Support Programme (ISP) :

An ISP can be made after a discussion with the parents, other teachers, and the school counsellor to cater to the unique needs that each child may have

Laboratory:

• They should be given preferential seating in the classroom to facilitate better listening or seeing the experiments being conducted.
• The students should be allowed to audio or video record the lab experiment so they can go home and recall them.
• A lab manual should be maintained where they can note/record the experiment conducted.
•  The child may be allowed to do simple tasks in the experiment to boost their confidence.
•  If students cannot do complex experiments, simplify them according to their comfort level.
• Lab instructions should be very simple and given one by one slowly so that the child has the time to process and understand them.
•  Extra time may be given to complete the experiment as the child may do the tasks slowly.

Cognitive Behaviour Therapy (CBT) helps people identify and change thinking and behaviour patterns that are faulty, harmful, or ineffective, replacing them with more accurate thoughts and functional behaviours. It can help a person focus on current problems and how to solve them.

Behaviour Therapy (BT) and Behaviour Modification are forms of psychotherapy in which the clinician focuses more on the behavioural changes and initiates the changes in undesired behaviour. This therapy is helpful in eliminating unwanted behaviour and increasing the desired behaviour through the help of reinforcement schedules.

Interpersonal Therapy (IPT) is a short-term form of treatment. It helps a person understand troublesome interpersonal issues, like unresolved grief, changes in social or work roles, conflicts with significant others, and problems relating to others.

Psychodynamic therapy is a form of therapy influenced by psychoanalysis. In this, a person works with the therapist to improve self-awareness and change old patterns, so he/she can more fully take charge of his/her life.

Supportive therapy uses guidance and encouragement to help persons develop their own resources. It helps build self-esteem, reduce anxiety, strengthen coping mechanisms, and improve social and community functioning.

Psycho-education provides education and information to those seeking or receiving mental health services, such as those diagnosed with mental health conditions (or life-threatening/terminal illnesses) and their family members. This is an essential component of all psychotherapy interventions.

Family Therapy is a form of intervention. Family therapy or family counselling is a treatment designed to address specific issues affecting the health and functioning of a family. It can help a family through a difficult period, a significant transition, or mental or behavioural health problems in family members.

Group Therapy is a form of psychotherapy that involves one or more mental health practitioners who deliver psychotherapy to several individuals in each session. Group therapy can reduce wait times and give more people access to mental healthcare. Some people attend individual therapy sessions in addition to group therapy, while others only use group therapy.

Psychotherapy for Children and Adolescents: Different Types

·         Acceptance and Commitment Therapy (ACT) helps a child understand and accept their inner emotions. ACT therapists help children and teens use their deeper understanding of their emotional struggles to commit to moving forward positively.  

·         Dialectical Behavior Therapy (DBT) can be used to treat older adolescents who have chronic suicidal feelings/thoughts, engage in intentionally self-harmful behaviours, or have Borderline Personality Disorder. DBT emphasizes taking responsibility for one's problems and helps the person examine how they deal with conflict and intense negative emotions. This often involves a combination of group and individual sessions.

·         Mentalization Based Therapy (MBT) involves working with children and teens who struggle with who they are. MBT is focused on helping children grow into healthy individuals.  

· Parent-Child Interaction Therapy (PCIT) helps parents and children who struggle with behaviour problems or connection through real-time coaching sessions. Parents interact with their children while therapists guide families toward positive interactions.

·         Play Therapy involves using toys, blocks, dolls, puppets, drawings, and games to help the child recognize, identify, and verbalize feelings. The psychotherapist observes how the child uses play materials and identifies themes or patterns to understand the child's problems. Through a combination of talk and play the child has an opportunity to better understand and manage their conflicts, feelings, and behaviour.

·         Supportive Therapy gives children and teens support in their lives to cope with stress, identify helpful and unhelpful behaviours, and improve self-esteem.

·         Child-centered play therapy (CCPT) is a play-based intervention. It utilizes the playroom as a safe space to help children process their feelings through symbols and play. The counselling relationship can support healing and positive change, decrease negative behaviours, and improve overall functioning. CCPT therapy allows children to explore issues using toys and the play environment, enabling them to lead their own healing.

7.6.1        Anxiety disorders:

Feeling anxious when something significant is about to happen is normal, but an anxiety disorder occurs when there is an extreme level of anxiety, even for minor things, and the person finds it difficult to control these extreme feelings.

The various types of anxiety disorders are as follows:

Ø  Generalized Anxiety Disorder

Ø  Social Anxiety Disorder

Ø  Obsessive Compulsive Disorder

Ø  Specific Phobias

7.6  Generalized Anxiety Disorder:

In this, a person feels anxious from time to time. Constant anxiety for small things or extreme worrying about everyday events for no rational reason is a significant part of Generalized Anxiety Disorder.

The other symptoms of Generalized Anxiety Disorder are as follows:

·         Dried mouth and palpitation

·         Restless or nervous about small things.

·         Shortness of breath, breathlessness, or chest pain.

·         Feeling nauseous frequently without any physical/medical reason.

·         Muscle tension or pain in the muscles.

·         Tired very quickly and may not even have the energy to do everyday activities.

·         Insomnia or significantly less sleep for just one to two hours

·         Unexplained or awful aches and pains in different body parts like the stomach, joints, etc

·         Continuous or frequent headache

·         A concise span of attention or may have difficulty concentrating.

·         Hot and cold flashes or excessive sweating.

7.6 Social Anxiety Disorder

A person with this disorder may show fear or extreme anxiety in social situations or interactions. They experience anxiety only when they have to interact with other people.

Some of the other symptoms of SAD are as follows:

·         People with SAD feel very anxious in social situations like family gatherings, parties, etc.

·         May feel very conscious about themselves in front of others and may think that others will humiliate, ridicule, embarrass or reject them.

·         Afraid that people will be judgmental about what they wear, what they do etc.

·         Avoid places or gatherings where they have to meet people.

·         Worry before and after going to a social event.

·         Extreme blushing, sweating, or being restless when other people are around them is one of the significant symptoms of this disorder.

7.6.1.3  Obsessive Compulsive Disorder( OCD)

It is a disorder where obsessive (repetitive) thoughts, images, urges or compulsive behaviour, or both affect the actions of an individual.

The other symptoms of OCD are as follows:

·         Repeated unwanted thoughts, urges, images

·         They repeat their actions, e.g., checking whether the windows are closed, lights are switched off, rechecking the lock, etc.

·         Repeated mental acts in their mind that other people cannot see or hear. For example, repeating a sentence often in their mind, counting the room tiles, etc.

·         Due to fear of getting infected, activities are repeated repeatedly. For example, mopping the floor repeatedly and washing the same clothes repeatedly.

·         They are obsessed with keeping everything properly and focusing on excessive symmetry or arrangements. They get very disturbed if the arrangement or symmetry is not followed. For example, if the books are slanting and not arranged size-wise, they get very irritated because of OCD.

·         Showing aggressive obsessions like wanting to harm them or others is a significant symptom of OCD.

·         Hoarding or collecting things at an extreme level that is of no use to them can also be a sign of OCD.

·         People may have only one kind of obsession and compulsion as described above or more than one.

7.6.1Depression

Every individual has both good as well as bad times in their life. It is normal to feel sad or low when something terrible happens, like the death of a loved one. A general feeling of sadness is not depression, but depression is when this sadness is prolonged for an extended period. Because of this, people lose their interest in life, or it negatively affects their actions or behaviour.

There are many symptoms of depression, varying from person to person. Each individual has their own experiences based on their situation. The various symptoms of depression are as follows:

·         Low mood and feeling down or hopeless for an extended period.

·         Loss of interest in things they used to enjoy doing. Lose interest in their favourite game or food etc.

·         Lack of energy even for the ordinary daily course without any physical cause.

·         Feeling sad and restless continuously.

·         Disturbed sleep is like too much or too less sleep.

·         Disturbed appetite, e.g., eating more or significantly less.

·         Self-harming or self-injurious behaviour.

·         Crying spells or breakdowns even in minor situations of life.

·         Agitated, irritable, or angry about small trivial issued things.

· Feel guilty for small things and blame themselves for situations beyond their control.

· Feel helpless and might not even be able to do the basic day-to-day activities.

·         Feeling worthless and having low self-esteem or self-confidence affects their overall behaviour and actions.

·         Aches and pains in different parts of the body like continuous headaches.

·         Lack of concentration and finding very decision-making difficulties.

·         Gaining or losing weight drastically depending on the change in their appetite.

7.Specific phobias- Immediate feeling of intense fear, anxiety, and panic when exposed to or even thinking about the source of your fear. Awareness that your fears are unreasonable or exaggerated but feeling powerless to control them. Some other significant symptoms are as follows:

·         Worsening anxiety as the situation or object gets closer to you in time or physical proximity like if the child fears lizards, he or she will get more anxious if the lizard is coming nearer.

·         Doing everything possible to avoid the object or situation or enduring it with intense anxiety or fear

·         Difficulty generally functioning because of your fear, e.g., if the child fears lizards, he will not even enter the room even if he will miss his/her exam.

·         Physical reactions and sensations, including sweating, rapid heartbeat, tight chest, or difficulty breathing

·         Feeling nauseated, dizzy, or fainting around blood or injuries if having a fear of seeing blood or injuries

·         In children, possibly tantrums, clinging, crying, or refusing to leave a parent’s side or approach their fear 

7.6.1.Post-traumatic stress disorder-Post-traumatic stress disorder (PTSD) is a mental health condition triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event. Anyone can have these symptoms after a traumatic experience, but if it persists for a long with increasing difficulties, then it is a matter of concern. Symptoms may be as follows:

·         Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating

·         Bad dreams and nightmares related to the adverse events

·         Frightening thoughts mainly related to the harmful event

• Staying away from places, events, or objects that are reminders of the traumatic experience
• Avoiding thoughts or feelings related to the traumatic event
• Being easily startled
• Feeling tense or “on edge.”
• Having difficulty sleeping
• Having angry outbursts
• Trouble remembering key features of the traumatic event
• Negative thoughts about oneself or the world
• Distorted feelings like guilt or blame
• Loss of interest in enjoyable activities

Symptoms in children may also include the followings:

• Wetting the bed after having learned to use the toilet
• Forgetting how to or being unable to talk
• Acting out the scary event during playtime
• Being unusually clingy with a parent or other adult

7.6.2        Bipolar Affective Disorder- Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Episodes of mood swings may occur rarely or multiple times a year. While most people experience some emotional symptoms between episodes, some may not experience any. Symptoms of the disorder may be as follows:

At the time of Hippomanic or Manic episodes, symptoms may be as follows:

·         Abnormally upbeat, jumpy, or wired

·         Increased activity, energy, or agitation

·         An exaggerated sense of well-being and self-confidence (euphoria)

·         Decreased need for sleep

·         Unusual talkativeness

·         Racing thoughts

·         Distractibility

·         Poor decision-making — for example, going on buying sprees, taking sexual risks, or making foolish investments

At the time of Depressive episodes, symptoms may be as follows:

·         Depressed mood, such as feeling sad, empty, hopeless, or tearful (in children and teens, depressed mood can appear as irritability)

·         Marked loss of interest or feeling no pleasure in all — or almost all — activities

·         Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight, as expected, can be a sign of depression)

·         Either insomnia or sleeping too much

·         Either restlessness or slowed behaviour

·         Fatigue or loss of energy

·         Feelings of worthlessness or excessive or inappropriate guilt

·         Decreased ability to think or concentrate, or indecisiveness

·         Thinking about, planning, or attempting suicide

Symptoms of bipolar disorder can be challenging to identify in children and teens. It is often hard to tell whether these are regular ups and downs, the results of stress or trauma, or signs of a mental health problem other than bipolar disorder. The most prominent signs of bipolar disorder in children and teenagers may include severe mood swings that are different from their usual ones.

7.6.3        Substance Abuse Disorder (Drug Addiction):-Drug addiction, also called substance use disorder, is a disease that affects a person's brain and behaviour and leads to an inability to control a legal or illegal drug or medication. When a person gets addicted, He/she may continue using the drug despite the harm it causes. Substances such as alcohol, marijuana, and nicotine also are considered drugs.

Drug addiction symptoms or behaviours include, among others:

·         Feeling that one has to use the drug regularly — daily or even several times a day

·         Having intense urges for the drug that block out any other thoughts

·         Over time, needing more of the drug to get the same effect

·         Taking more significant amounts of the drug over a more extended period than intended

·         Spending money on the drug, even if the person cannot afford it

·         Not meeting obligations and work responsibilities or cutting back on social or recreational activities because of drug use

·         Continuing to use the drug, even though the person knows it is causing problems in their  life or causing  physical or psychological harm

·         Doing things to get the drug that generally a person would not do, for example, stealing

·         Driving or doing other risky activities when under the influence of the drug

·         Spending a good deal of time getting the drug, using the drug, or recovering from the effects of the drug

·         Failing in the  attempts to stop using the drug

·         Experiencing withdrawal symptoms when the person attempts to stop taking the drug

Sometimes it is difficult to distinguish normal teenage moodiness or angst from signs of drug use. Possible indications that your teenager or other family member is using drugs include:

·         Problems at school or work — frequently missing school or work, a sudden disinterest in school activities or work, or a drop in grades or work performance

·         Physical health issues — lack of energy and motivation, weight loss or gain, or red eyes

·         Neglected appearance — lack of interest in clothing, grooming, or looks

·         Changes in behaviour — exaggerated efforts to bar family members from entering his or her room or being secretive about where he or she goes with friends; or drastic changes in behaviour and relationships with family and friends

·         Money issues — sudden requests for money without a reasonable explanation; or the discovery that money is missing or has been stolen or that items have disappeared from  home, indicating maybe they are being sold to support drug use