KUALA LUMPUR, October 5 – Civil societies are calling for more active government intervention in dealing with mental health issues among children and adolescents in Malaysia, as cases of depression, self-harm and suicide rise.
Mental health advocate Hasbeemasputra Abu Bakar said the Ministry of Health (MOH) should not “offload” its duties in addressing the mental health crisis, especially among children, to civil societies and mental health advocates by being “inactive”.
Hasbeemasputra said the government’s lack of engagement in mental health has placed the burden on activists, non-governmental organisations (NGOs), and the private sector to reach out to and aid those suffering from mental health issues.
“If the public sector cannot work 100 per cent for the people, then it is not working. I understand there are barriers to actually getting 100 per cent coverage, but I don’t think the public sector is doing enough.
“I think it is a cop-out for them to outsource responsibilities of the state to private stakeholders,” Hasbeemasputra told CodeBlue in a recent interview.
Hasbeemasputra said there needs to be serious intervention from the government to make information on mental health care more accessible, in addition to accessible treatment.
He said the lack of public information has not only led to the stigmatisation of mental health, but also parents believing that their children are getting the right kind of care when, in actual fact, more harm is being done.
Hasbeemasputra said even the MOH’s website does not provide meaningful information about the different mental health conditions that Malaysians may have.
“I would usually get everything from the National Health Services, a UK website, or maybe WebMD. But why don’t we have anything localised, in the local languages, and in various formats that would be accessible for a disabled person.
“A lot of it (information) is being heavily subsidised by lived experience advocates. A lot of weight is being picked up by advocates in society, and it’s great that people are stepping up. But we are not dealing with the actual problem,” Hasbeemasputra said.
The lack of mental health information and services, coupled with stigmatisation, result in parents falling back on superstitious beliefs in desperation to help their kids, Hasbeemasputra said.
“Even if you have parents who do acknowledge that their kids have mental health issues, who is the first person they look to for help? Do they see a mental health professional or do they seek a resident bomoh? Which is more accessible? It all boils down to accessibility.”
A 2019 article by the New Straits Times reported that it was “common” for families to view members with mental illness as “victims of black magic”, hence why traditional treatment is sought instead of medical help.
“Whenever someone receives a life-changing diagnosis, whether it be for cancer or clinical depression, that diagnosis itself is traumatic,” Hasbeemasputra said. “And our systems do little to help that person come to an emotional and psychological acceptance.”
“There may be a rational and logical acceptance of the diagnosis, but there is an emotional and psychological barrier to accepting it, because you are really losing a part of yourself. I think there is a gap in access,” Hasbeemasputra added.
To help children and parents get the help they need, Hasbeemasputra called for school counsellors and people with lived experience to act as bridges between patients, their families, and psychologists.
“After they get their diagnosis, help them (the patient) through the process of acceptance, because once you get them through the process of acceptance, the client will feel more empowered to take charge of their own recovery, and they will be more proactive clients, which would lead to better health outcomes.”
Poverty Linked To Poor Mental Health
Unlike children in the middle and upper-income brackets, cases of mental health for children in the lower-income bracket are often associated with or rooted in poverty.
Consultant paediatrician Dr Amar-Singh HSS described poverty as a “lifetime trap” that reduces a family’s ability to cope with psychosocial stressors such as relationship difficulties, loss of employment or savings, loss of loved ones, bankruptcy, and isolation.
“They have no reserves and are constantly pushed to the edge,” Dr Amar told CodeBlue in a written statement. In turn, this creates a vicious cycle between mental health and poverty.
An article published by the Association of Commonwealth Universities (ACU) stated that people who live in poverty – who may be unemployed and lack adequate housing and basic amenities – are more likely to be at risk of mental ill-health.
This is known as the social causation pathway, and is thought to occur due to heightened stress, social exclusion, decreased social capital, and increased violence and trauma that people living in adversity are likely to face. Research shows that these social determinants tend to lead to common mental disorders, such as depression and anxiety.
On the other hand, people who suffer from a mental illness are more likely to drift into or remain in poverty as a result of reduced productivity, loss of employment, and increased health expenditure. This is known as the social drift pathway.
In short, poverty leads to poorer mental health, and vice versa, leading to reduced opportunities for economic development and increasing the risk of lifelong poverty. Hence, the vicious cycle.
The National Health and Morbidity Survey (NHSM) 2019 reported that 8.8 per cent of 424,017 children with mental health problems in Malaysia were from low-income or bottom 40 per cent (B40) income households.
About 11.9 per cent came from households with an income of RM 1,000 to RM 1,999, and 10.1 per cent came from households that made less than RM 1,000.
Dr Amar said a child’s psychosocial health – interaction of social, cultural, and environmental influences on the mind and behaviour – cannot be viewed in isolation when dealing with child mental health, especially with Covid-19 exacerbating poverty and economic instability.
A study titled “Depression and Anxiety in Malaysian Population During Third Wave of the Covid-19 Pandemic” published in the Clinical Epidemiology and Global Health Journal last year found that out of 1,544 participants aged 15 years and older who were surveyed from January 15, 2021, to April 15, 2021, during the movement restriction took place, about 25.1 per cent displayed severe depressive symptoms, 18.7 per cent (one-sixth) had mild depressive symptoms, and 34.1 per cent (one-third) had mild to moderate anxiety symptoms.
In his online workshops with parents and children, Dr Amar found that 10 to 12 per cent of parents were very concerned with their child’s mental health and another 40 per cent said that extra effort is required to support their children during the Covid-19 pandemic. Forty-two per cent of children interviewed in the online workshop expressed a loss of social interactions.
“The pandemic, with its fears and need for masks and vigilance, has made our children ‘grow up too fast’ and become a ‘fearful generation’,” Dr Amar said.
“Studies in other countries have suggested that we may have an increase in long-term phobias or fears, post-traumatic stress disorders (PTSD), and suicides.
“The American Academy of Paediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children’s Hospital Association (CHA) have all come together to declare a National State of Emergency in Children’s Mental Health in the United States.”
In Malaysia, most public mental health services are targeted toward “serious mental health problems” like psychosis and depression and they are predominantly “developed for adults” and are “not child-friendly”, said Dr Amar, adding that private services are often out of reach for many people who need it the most, but are unable to afford such services.
Acknowledging the principle behind the MOH’s National Adolescent Health Policy, Dr Amar said in practice, the situation is much more complex.
“In practice, from anecdotal data, there may be problems with clinic staff who respond to teens from their religious or cultural perspectives and can limit access to services.
“In addition, clinic staff are grossly overworked with their huge expanded scope of services (expanded from maternal and child health to elderly and adolescent) and not able to deliver the service effectively,” Dr Amar said.
The National Adolescent Health Policy is the policy behind the Adolescent Health Programme which aims to develop and improve adolescent health services. This programme is available at any government health clinic nationwide and is for those aged between 10 to 19 years.
“If we want to help children and adolescents improve their mental health and psychosocial wellbeing, parents, teachers, leaders and society must change first. Our value system (i.e. financial achievement focus) and lifestyle of phone and screen addiction, do not support psychosocial wellbeing in children or society,” Dr Amar said.
Dr Amar added that the Treasury Department needs to take a more proactive approach to families facing financial difficulties by ensuring that they have a safety net to help them establish meaningful long-term occupation.
“The Treasury Department needs to proactively support all vulnerable families, especially those lacking food security or are in financial difficulties. We need to assure these families of a secure safety net, while we help them establish meaningful occupations long term.
“We need to fund after-school care services in poor urban localities and poor rural communities. These centres can be community hubs where children can receive support and help, while offering their parents respite and the opportunity to engage in employment,” Dr Amar said.
Mental Health Care For Children With Special Needs
Wo Su Woan, a lecturer for Sunway University’s psychology department, noted that mental health is not addressed when it comes to atypical children, or children with special needs.
“We don’t actually talk about mental health (in atypical children). Throughout my time as a special needs teacher and through interviews I have conducted with parents and children, many parents raised several experiences of their child breaking down because of limited physical activities or a disruption in routine due to the Covid-19 pandemic.
“We have to be very flexible in these difficult situations, but some kids are not flexible. So, they break down very easily and the parents just have to let it be,” Wo told CodeBlue.
This lack of mental redress for atypical children comes as a result of misunderstanding and a lack of awareness of the signs that these children display.
“Sometimes they will hurt themselves. You would think that they are asking for attention or they don’t want to do certain things, so you think they are trying to escape – but sometimes it’s a mechanism. This happens with parents who don’t know about anxiety or depression in autism children,” Wo said.
When faced with these different manifestations of emotions, Wo questioned how the DSM 5 – a publication that contains the most up-to-date criteria for diagnosing mental disorders – can be applied to atypical children.
These different manifestations of emotions make it difficult for parents to identify when their children are feeling depressed or anxious, especially when they have devoted most of their time and attention to caring for their children’s physical needs.
“Only when it is very obvious, when there is an outburst already of the depression but there is no prevention screening. And a lot of [existing] screenings are very difficult [to apply],” Wo said.
To help parents and caregivers better understand the needs of atypical children, Wo proposes integrating mental health and special needs awareness into the school syllabus and having parenting workshops in this area.
Wo said instead of adding an additional class that will place a greater burden on students and teachers, she proposed that mental health and special needs awareness be inserted into pre-existing subjects.
By integrating mental health and disability awareness into subjects like English, Bahasa Melayu, Chinese, and Tamil, the learning and teaching of these issues becomes more organic, Wo said. Parents, too, will become more informed on these issues as they guide their children through their homework.
As for parenting workshops, Wo suggested that the government invest in workshops for parenting like they do for marriage.
Wo said counselling and workshops are very important to ensure that parents – especially future parents – have information on the realities of parenthood and that the right expectations are created.