Magazine 2012
A Mental Health Initiative
Ms. Asma Shaherwalla
Maniben Nanavati Womenb s College,Mumbai.
Mental health promotion in India is very relevant. Education in India is achievement oriented rather than learner
centric. It pays scant attention to the childb s needs and does not empower them to live effectively in this world.
The rapid globalisation and urbanisation has impacted the socio-cultural and thus the psychological milieu
.There has been a breakup of the joint families, values and traditional support systems .An adolescent empowered
through Life Skills Education has the competencies to cope effectively with these challenges. The present
paper draws upon the data of the application of the NIMHANS model which focuses on 4 areas i.e. coping, self-
esteem, adjustment and psychopathology. Using experiential learning and participatory methods, the model
has reported significant gains in self-esteem, adjustment and pro-social behaviour of the experimental group.
The present paper using secondary data discusses the relevance of the model and offers suggestions to
enhance its applicability
Key words: mental health, adolescents, life skills education, experiential learning, empowerment
st
Mental Health is likely to be a major component of the global burden of disease in the 21 Century. Almost 20%
of all children and adolescents are affected by mental health problems. Child abuse, conduct disorders, substance
abuse, depression, suicide, neglect, attention deficit disorders, are not only common but have an early age of
onset and increase in severity.
According to UNESCO report (2008) India is at
nd
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102 position out of 129 countries in Education for all Developmental Index
nd
132 place out of 172 countries on b Human Development Indexb 46% - 50% of Indiab s large population
comprises of Children and adolescents. Ten percent of 5 b 15 years olds have a diagnosable mental disorder.
0 million adolescents have a severe mental health disorder 90% of those affected do not receive any specialist
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service.
A large gap exists in the prevention; promotion and early intervention in the area of mental health. WHO has
noted that in spite of availability many psychiatrically ill remain untreated globally. One in every 5 child has a
mental health issue. Early and timely intervention will be cost effective and prevent adult treatment and
rehabilitation. Thus high quality integrated health and social care for children, before birth, right through to
adulthood assumes significance.
Independent India has addressed issues of child education, health and development but has ignored child
mental health generally. There exists a gap between childrenb s need and existing resources. There is neither an
independent nor integrated child mental health policy in India. Formulating such a national policy is challenging
especially because India is a secular state marked by heterogeneity of languages, cultures and religions.
Though 7 policies have been formulated between b 74 to 2007b , the gap between planning, policies and effective
implementation has been too wide to make an impact. Yet there is hope since authorities are taking a serious
th
look at the issue. The 11 Five Year Plan (2007) is child centric, includes policy for child mental health, school
mental health and mental health for the disabled.
Traditionally in India, child care rests largely with families and communities. Their personal, educational, economical
and sexual needs are generally ignored. Thus b identity formation is amorphous and self b worth low (Shastri,
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008, 2009). As Shastri (2009) pointed out that children in most sections of Indian society are not consulted
about matters that affect their lives. When children express their view, they are not heard. Restrictive norms are
imposed, especially true for a girl. This limits childrenb s access to information and their seeking help outside the
family.
Child mental health is a shared responsibility b effective intervention requires a synergy of efforts by all
stakeholders. A mechanism involving parents, teachers, medical practioners, police, social workers and policy
makers is needed. Mental health problems in children arise due to educational failure, family disruption, disability,
antisocial behavior. This places demands on social services, youth and the judicial system. When untreated,
mental health problems create distress in children, adolescents, their families and care givers. These issues
continue in their adulthood, affecting the next generation.
Dr. P. C. Shastri (2009), in the presidential address to the Indian Psychiatric Society, has stressed the need for
promotion of mental health and early intervention. A number of issues need consideration for the promotion of
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mental health in India. There is a need for an effective partnership between agencies, a multidisciplinary team,
working in a community mental health clinic or out patient service. This would provide specialized care for
children and adolescents with all types of disorders. Especially people with severe, complex and persistent
disorders would be taken care of. Such services should be made available irrespective of gender, race, and
religion culture. 90% of Indian children with a mental disorder are not currently receiving any specialist service.
Many who could benefit from mental health services for assessment and treatment are not accessing services.
A lack of trust in statutory services, a wish to solve problems themselves, a fear of being stigmatized, a belief
that nothing can be done may be the cause. The stakeholders require access to information and supportive
environments. Tackling bullies, awareness of mental health issues, recognition of childrenb s emerging needs,
support for people with particular needs, play a vital role. Everyone in a community has a role to play in
ensuring that the environment in which children are growing up promotes mental health. A nurturing social
environment, effective early education, academic success, protects the mental health of the young. Assessment
of local needs may help identify at risk groups e.g. homeless children, adolescents in correction homes,
asylum seeking children.
Proper planning for promotion of mental health requires updated incidence database of various types of illness
which is lacking (Malhotra et al, 2009). The role of the media in spreading awareness is crucial. Debates and
discussions can enhance knowledge and sensitivity. India has 179 languages, 544 dialects, 1942 mother tongues,
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48 mediums of instruction. Being a complex and multi faceted country, planning national policies is a gigantic
task. Concepts of mental health and illness vary across cultures. Thus services need to be sensitive to these
differences and work effectively with these heterogeneous groups.
A nationb s children are an important asset, our human resource, our future. Though effective models of human
health promotion are available, they are often underutilized. Successful programs involve long term intense
interventions that address variety of factors like family, conflict, depression, social isolation, school failure,
substance abuse delinquency and violence. Training should consolidate existing knowledge through experiential
learning, enabling staff to recognize and mange childrenb s and adolescents mental health issues. One such
model has been developed and practiced at NIMHAMS by Bharath, Kumar and Vrinda (2002)
Mental Health Promotion among adolescents in school using life skills education (LSE) and teachers as like skill
educators is a novel idea. As noted by Kapur (1997) the school mental health program (SMHP) is a very
important and integral part of the education system worldwide. In India, the SMHP is yet to be recognized and
initiated as a part of the health component in schools. In practice it is restricted to individual work by child
mental health professionals especially in big metropolitan cities focusing on sensitization of teachers on child
developmental and mental health issues. Counseling services for students with persistent emotional issues and
a referral system is set up in a few urban clinics.
In this rapidly changing social scene of India an empowered child has the competence to cope with the
challenges of life using the available resources even amidst adversities (Patel, 2005). Methods to improve the
psychosocial competence and resilience of the adolescents as health promotional activities and development
oriented approach need to be included in the school syllabus and provided as much relevance as the Three Rs.
(
Bharath, Kumar and Viranda, 2002).
The aim specifically was to assess the difference between the adolescents who were in the LSE program
NIMHANS model) for a year and the ones who were not in the program. The skill areas identified for training
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were:
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b "
Coping
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b "
Self b esteem
Adjustment in various areas
Psychopathology
The model uses experiential learning with peers and uses participatory methods thus enabling the adolescent
to develop psychosocial skills.
Life Skills
Life skills (LS) are abilities for adaptive and positive behavior that enable individuals to deal effectively with the
demands, challenges, and stress of everyday life. Childhood and adolescence are the developmental periods
during which one acquires these skills through socialization and interaction with significant others. (Bharath,
Kumar and Viranda, 2002).LS training is designed to provide information relevant to important life transitions
that adolescents and young teens face using culturally sensitive and developmentally and age appropriate
language and content. Such training addresses multiple risk and protective factors and teaches personal and
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social skills that build resilience and help youth navigate developmental tasks. Facilitated discussions, structured
small group activities and role playing scenarios were used.
The following life skills have been identified as important.
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b "
b "
Critical thinking and creative thinking
Decision making and problem solving
Communication skills and interpersonal relations
Coping with emotions and stress
Self b awareness and empathy were the focus of the NIMHANS program.
The efficacy of a life skills training approach has been reported by various studies. Hanrahan (2008) reported
significant increase in global self worth and perceived life satisfaction after fifteen sections of physiological skills
training with adolescent Mexican orphans. Botvin et.al.(2000)and Fraguela et.al.(2003) reported lower levels of
tobacco, alcohol and drug consumption after a year of follow up of adolescents who had received life skills
training compared to a control group. Botvin, Griffin and Nichols (2006) found a significant reduction in violence
and delinquency for intervention participants relative to controls, the effect being stronger for students who
spent more hours in training. Botvin, Baker, Renick, Filazolla, and Botvin (1984) found that training by older
peer leaders and regular classroom teachers had a significant effect on cigarette smoking, excessive drinking
and marijuana use. Cognitive, attitudinal and personality predisposing variables changed in a direction consistent
with non-substance use.
To implement the program as a project, the first step was.
b "
Capacity building by training of the teachers by master trainers over 3 days. More than 1000 teachers
were thus trained from 261 schools over 3 months followed by Evaluation of the training.
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Implementation of the LS program in the identified secondary schools once a week for an hour over 12
to 20 sessions during the academic year.
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Impact of the program on a sample of adolescents at the end of 1 year.
Sample
The sample and control were selected from two schools in the Bangalore rural district (Chennapatna) and two
schools from Udipi District. The control adolescents were selected from secondary schools in the same district
as the sample group. Selection of the school was random.
A total of 605 students were taken as the sample group. Adolescents of both sexes 14 to 16 years studying in
th
th th
8
, 9 or 10 standard in the two schools (Bangalore rural and Udipi) implementing the NMHANS model of the
LSE program the previous 1 year were selected. Informed Consent was taken from the parents as the adolescents
were minors. These adolescents had undergone on an average of LSE classes during the previous year (minimum
5
and maximum 16 sessions).
A total of 423 students were assessed as controls. They were adolescents of both sexes, 1 to 16 years studying
th
th
th
in 8 , 9 or 10 standard, in secondary schools not covered by NIMHANS model, of LSE (or other adolescent
education programme). Informed consent was taken from their parents also.
Tools
Rosenberg Scale of Self b Esteem (RSES, Rosenberg 1956). It has 10 statements rated on a 4 point scale of
strongly agree, agree, disagree, strongly disagree. Sample statements are b I take a positive attitude towards
myself.b , b At times I think I am no good at all.b
Preadolescent Adjustment Scale (PAAS, Pareek et. al. 1975)
This has 40 ststements to asses adjustment in 5 areas of home, school, teachers, peers and general behavior to
be answered in yes or no. Sample items are b I like my parents very much.b ,b The rules of the school seem
senseless to me.b ,b I shall be happy if my teachers leave.b ,b Some of my friends are good.b , b I do not get angry
easilyb .
Generalized Self Efficiency Scale (GSES Jerusalem and Schwarzer 1995)This has 10 items rated on a 4 point
scale 1 = to not at all true, 2= hardly true, 3= moderately true, and 4= exactly true. Sample items are b I can
always manage to solve difficult problems if I try hard enoughb , b It is easy for me to stick to my aims and
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accomplish my goalsb .
Strengths and Difficulties Questionnaire b Self b Report Version, (SDQ SRV Goodman et. al. 1998)
This is a 25 item scale with 5 items for each of the areas of emotional symptoms, conduct problems, hyperactivity/
inattention, peer relationship problems and prosocial behavior. Both positive and negative items are rated on a
3
point scale of not true, somewhat true and certainly true. Sample items are b Often lies or cheatsb , b Generally
well behavedb , b Has at least one good friendb .
Class room Indicators. A simple checklist was designed for the teachers who did the LSE classes eliciting
observable changes in the class room behavior of the students before and in LSE classes.
Results and Discussion
The study groups i.e. both the sample and the control group did not differ in age and sex or socioeconomic
status (P = 0.001) as they were pre b selected form specific classes in government secondary schools. Their
age ranged from 155 to 200 months (mean 175 B1 13.8 months. 35 to 40% of the study groups were girls.
According to their self b report, the students in the program in comparison to those not in the program were
significantly better adjusted to the school and teachers; opined that they were capable of coping with issues
with better self b esteem, the changes being reported in a follow up, a year after the intervention. Feedback from
100 teachers showed positive changes in the classroom behavior and interaction among students in the program.
Comparison of students in the LS program with controls is given in table 1.
Table1:Comparison of students in the LS program with control
There was no difference between the groups in adjustment with parents and peers. There was no difference
between the groups in adjustment with parents and peers. There was no difference between the groups in
adjustment with parents and peers. There was no difference between the two groups on psychopathology
assessed by Strengths and Difficulties Questionnaire (SDQ).
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LSE is a novel promotional program that teaches generic LS through participatory learning methods of
games, debates, role- plays, and group discussion. Conceptual understanding and practicing of the skills
occur through experiential learning in a non b threatening setting. Such initiatives provide and adolescent with
a wide range of alternative and creative ways of solving problems. Repeated practicing of these skills leads to
certain mastery and application of such skills to real life situation and gain control over the situation. It is a
promotional program, which improves the positive mental health and self b esteem. Our country places a
premium on values. LS program empowers the youth to choose the appropriate values and behavior which are
ingredients of positive health. LS are the processes that will make the target of values possible. The NIMHANS
model of LSE positive health. was planned to be experiential, participatory and activity based for the students.
b
Didactic methodologyb or b adviceb was not part of the model at any level. Cultural sensitivity was maintained.
Most of the programs done earlier have evaluation of implementation b money planned spent, measurement of
capacity building, and extent of training and conduct of program. Impact of an effective preventive / promotional
program is of paramount importance and has been discussed at length. The significant strength of the present
health promotion using the LS approach (NIMHANS model) has been the evaluation at every level. Original
resource materials in English and later even the translated resource materials were evaluated and modified both
by expert professionals and the end users (teachers). Trainings both at the level of the master trainers (MTs) and
the teachers were evaluated both qualitatively and quantitatively b the effectiveness of training was established.
The positive effect of LSE program in student b teacher interaction, academic performance, and peer interaction
has been established by others in the West (Weisberg, 2003). Perceived self b efficacy (P = 0.000), better self
b
esteem (P = 0.001), and better general adjustment (P = 0.000) were important aspects which were significantly
different between the two groups, indicating that the program prepares the adolescent to be a b competentb and
empoweredb person in a changing competitive, globalized world. (Greenberg et.al, 2003, Nation et.al 2003)
b
Conclusion:
The present study of the NIMHANS model of LS program is a suitable and an effective school mental health
program. The highlights of the model / program are as follows:
1
.
Comprehensive health including mental health through psychosocial competence in adolescents is the
goal to empower the adolescent.
2
3
4
.
.
.
Using life skills as the medium / process
Providing a structure to the program by activities
Teachers as life skill educators / facilitators/ Evaluation of the Impact of the model shows that it improves
adjustment of the adolescents with teachers, school, increase prosocial behavior, coping, and self b
esteem, as there was a significant difference between the groups in the program and not in the program.
References:-
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