Category: Child & Adolescent Mental Health

Interesting stuff about how children think and issues related to their mental health

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Perspective affects decision-making

18 month old child is brought in by parents as they suspect autism.
Pediatrician saw the child 3 months ago and advised them to wait till second birthday.

Parents were worried so they self referred to me.

Should the parents consult me without knowledge of their regular pediatrician?
(Hearing test is already done. Normal.)

When I meet the family, child has definite delay in speech related milestones. All other milestones are fine. Signs of autism are absent.

Parents ask a pointed question – “Are you sure my child does NOT have autism?”

What are my choices ?-

Fact – child has no classical early signs of autism but there is no guarantee that over next one year they will not develop at all!


Yes, that’s how it works. There is teeny-tiny chance of going on to develop autism from here but small is never 0 in medicine.

Ideally – I should explain the complexity of “diagnosis” to parents, ask them to visit speech therapist for speech stimulation work and reassess after 3-4 months again.

This is what I did. They left. Clearly not pleased or sufficiently reassured.

I saw them again after a year after this consultation at a theater. Toddler was with them. Child still has no speech at all but is very sociable, smiley, reaches out to people like a normal child, plays nicely with other kids. No sign of autism at all.

Curiosity got better of me and I asked them about their journey after meeting me. They met several other specialists of child development, did various development tests over last year.

None showed autism. But still no specialist gave them “guarantee” of “no autism ever”.

Now, for someone working in this area, it is clear that parents are on a sad quest. They are asking wrong question. “Why does my child not speak? What should we do about it?” is a correct question. This question can help move things.
Their focus on autism is a problem. Unfortunately, they don’t want to start speech therapy till “clear diagnosis” is given.

So here is a child with significant speech delay who hasn’t received any help yet except a ton of tests. I feel bad for the child, parents, their first pediatrician (he was absolutely right in calling them back after second birthday).

This is a typical path of “pay as you go” medical system where people with money can purchase whatever healthcare they desire. Here I don’t think anyone is “wrong” but lack of trust combined with anxiety has ruined one year of their life. And will continue to do so.

They are already bitter about modern medicine now. It will take one charlatan alternative therapist to tell them “oh, now it is quite late. Allopathy has no real answers” and “try” XYZ therapy.

Anxiety and pay-as-you-go healthcare is a loss-loss combination for all except crooks.

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Back to the roots for Psychiatry?

Psychiatry is presently not as ostracized as it once used to be, confined to asylums.

Now a days you may even find psychiatrists invited to public functions.

A welcome change but likely to be short lived.

Why?
Read on – #stigma has always been a huge problem for psychiatry.

We got mental health away from Shamans but managed to get stigma in the process.

Persons with mental illness were always feared and hated. Hence confined to asylum, away from sanitized life of people. Anything perceived as threatening (mentally ill, free thinking women, disenfranchised minorities, political opponents, sexual minorities) was labelled as “madness/character flaw/unsoundness” etc and sent to asylum to spend rest of their life. Psychiatrists worked in such places. Looking after those who were unwanted by the world. They made sense of this madness.

As medicine progressed, neurological basis were discovered and most importantly, prescriptions could be written to achieve “cure”. History of psychiatry shows that as soon as something is discovered to be –
1. Treatable by talk therapy (depression, anxiety, relationship issues, etc.)

2. “neurodevelopmental” to be treated with some medicines but largely support (autism, ADHD, intellectual retardation)

3. Effectively treatable with medicines (epilepsy, movement disorders)

It is moved to mainstream medicine and treated by psychologists, pediatricians and physicians/neurologists. Stigma continues to work strongly in society but MORE PROMINENTLY among medical doctors.
They are afraid of serious mental illnesses that involve losing “sanity”.

That means – Schizophrenia, Any psychosis, Bipolar disorder.


In India almost no non-psychiatrist doctor knows about “Phenomenology” and “mental status examination”. So they think psychiatrists just talk with people and give labels.

As we develop more effective medical and non-medical therapies for various ills of brain and mind,
psychiatry is headed back to asylum, its birthplace. A psychiatrist is trained in “bio-psycho-social” model to look after all aspects of mind-brain-body-self-others complex.

We are gradually handing over care of mentally ill to part-specialists because it is less stigmatizing (though not necessarily any cheaper or better). This leaves care of only seriously ill to psychiatrists and psychiatric nurses.

Sometimes in asylums, sometimes in community (not necessarily integrated with society).

“Mindless psychiatry” and “brainless psychology” is often rightly criticized. Now we have entered era of “narrative based mental health”

Where does it stand as science? How does it serve society? Is getting rid of multidimensional model specialists a really good idea?

Are we throwing away baby with bathwater?

I leave you to think and comment on this rapidly turning tide of twenty first century mental health.

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Managing your anxiety about Covid

If you are worried about catching Covid while at home, you can try these simple steps to reduce your worry –

1. Use small chunks of time (15-30 min) by allocating to specific activity

2. Do not re-work plans – e.g. if you are buying groceries once a week stay with it.

3. Stop looking for more info – avoiding crowd + closed spaces and wearing mask all the time is enough.

4. Washing hands ONCE after returning home is good enough.

5. Watch your emotions – distract yourself from worry, anger, sadness by involving in physical activity, art, music, etc.

6. Step away from Covid conversations in person and online.

7. Spend time with children doing chores at home, study etc.

8. Get exercise as possible.

9. Simple slowed breathing with long exhalations is helpful. Start with just 10-15 breaths multiple times in a day. Don’t stretch concentration to breaking point.

10. Call up elderly relatives for light chat and help them remember “good old days” avoid Covid discussions with them.

11. Get good sleep by switching off screens hour or two before bedtime and take light dinner.

12. Start writing – whatever you want. May be just a written record of your free running thoughts. It helps to calm mind. Usual caveat – this does not apply as treatment of mental health issues.
If distress continues beyond 2 weeks and affects your sleep, appetite, mood on daily basis, get help.

Take care.

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Coping with loss of parent or family member

Over last few months many mental health practitioners like me have received requests about grief counseling due to death in family (due to Covid 19)

A short article on helping kids deal with early days of grief.

First of all – all bereaved persons do not require grief counseling –
Culture and traditions help us deal with loss of loved ones in most situations and then there are time and life , the great healers.

So please don’t rush in with psychological help on day one. When death is untimely i.e. a person who dies earlier than old age, it can get complicated.

Many factors add to trauma of grief in pandemic –

1. Trauma of finding treatment for Covid19
2. possibility of immediate family being sick or in isolation complicates things. 3. Denial of usual rituals associated with dead.
4. Lack of extended family and friends’ physical presence to soothe the grieving persons
5. Loss of more than one member of family

List just adds up. My focus in this thread is in helping children in the family to deal with first few weeks of grief. Key issue is “primary attachment figure for the child”
The person who is emotionally closest from child’s point of view, who is approached by child to share all good and bad experiences, the person who is child’s support in all aspects is primary attachment figure (simplified) Usually this person is mother. But grandmother, father, elder sibling can also be in this or a similar role.

If primary attachment figure is intact, child are well buttressed to handle grief. What happens when this key person in child’s life disappears suddenly ?

Some simple steps can help the child cope better –
1. Let the child know about hospitalization. Don’t keep it secret.

2. Let the child know about deteriorating condition (if applicable) and passing away of the person.
3. Let another member of family take the role of mother (usually it is grandmother or father in urban families)

4. Let the child realize that they are supported and looked after by actions NOT by repetitive sermons.
5. Whatever belief about “after death” existence is accepted by the family should be offered to the child.

6. Let the child express their grief freely in a manner they find okay. Don’t try to suppress their crying and grief expression because it is too much for you to bear.
7. Offer help at bedtime. Many kids can’t sleep by themselves at such times.

8. Let the child settle down with family before exposing to visitors.
9. Don’t stop the child meeting friends and playing if child desires so.

10. Routine is healing. Let the child carry on with school, play, study activity as soon as possible. I have met kids who attended school next morning. This is perfectly okay.

11. Do not go overboard in caring for the child. Infantalizing them is not a good idea.
12. Let siblings help each other.
13. Children feel safe when they see confident adults around them. Sense of continuation is important for them.

14. Some young children ask “who is going to feed me? Who will take me to toilet? Who will tell me bedtime story?” These are legitimate needs of a young kid. They are not being selfish. They are scared. Give reasonable answers. Let them know that they are supported. It is never easy to talk to or look after a bereaved child. Have faith in nature and our in born ability to overcome loss.

Please do not shut the child away from last visit to the dead. Give the child a choice if they want to see the dead body and pay their respects. This is important for the child. Children as young as 3 or 4 years have participated in last rituals of their mother sitting in lap of father. This can help the child if they desire so.
Let the child move away if they are uncomfortable in the rituals.
Choice should be child’s. I hope none of us face this situation. But life and pandemics don’t follow our wishes.

When should you look for formal psychological help?
Few pointers –
1. Inconsolable state of child even when close family members are available. 2. Serious sleep and appetite disturbances lasting beyond few days
3. Regression – child going to psychological state of much younger age e.g. bed wetting in a grown child 4. Searching for the dead intensively or denial of death lasting beyond few weeks
5. Most importantly – inability to connect with another adult.

Don’t take the child with you for first professional consultation if possible. Many times it is possible to help the child via family members.

I hope you and friends don’t have to face this situation and all this information is completely wasted.

May the force be with us all.

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Preventing Suicides : What can you do?

10th Sept is World Suicide Prevention Day.

We all know that 800,000 people die every year due to suicide. 250,000 of those are Indian. So every third suicide happens in India.

Though Suicide is biggest cause of death for young Indians (15-30 age group), we do little about it.

Can you help someone stay away from suicide?

In this blog, I try to give simple tips to help you prevent suicide without feeling overwhelmed. Everyone can help.

1. All of us feel suicidal at times. Nobody is immune. If you haven’t felt it so far, give life a chance. In spite of my years of training and work in Psychiatry, I have felt suicidal at times and at least twice i was quite close to ending my life but my therapist saved my life with regular support in therapy.

2. As of now, we don’t know precisely what causes final act of suicide. People reach that point through various pathways.

3. One thing is sure, loneliness and hopelessness contribute a lot to final stage. Anger may be a big push for some who die by impulsive acts of self destruction.

4. So, whenever you realize that your friend, acquaintance, lover, student, neighbor, relative, is avoiding people , you should ask if they are okay.

5. If you are wondering about their suicidal thoughts, ask them a direct question about it. Asking is the best way to help. Dont be afraid that you may INDUCE suicidal thoughts in their mind by asking such questions. You will NOT be inducing suicide by asking.

6. Offer to talk, brew a cup of tea/coffee/hot meal. Don’t advice. Just hear them out. At the end, thank them for trusting you with all the information, thoughts and feelings.

7. Ask what you can do to help them feel better. It is a simple question but a powerful one at the end of patient and helpful listening.

8. Keep in touch. Don’t disappear from their life after this conversation.

9. If you feel overwhelmed, don’t be afraid of saying that (“it is so much to experience. Listening to your experience is overwhelming for me. I don’t know how you brave it all. Tell me how do you cope with this?”)

10. When you feel worried about their safety, call a helpline. All cities have suicide prevention helplines.

11. Lastly, remember, company and patient listening are most powerful tools to prevent suicide.


A supportive hand in hand and a patient ear goes a long long way.
Get professional help whenever it crosses your desire to help.

If you want to read Marathi translation of this article, my friend Prasad Shirgaonkar has posted it on his Facebook Page, https://www.facebook.com/prasad.shir/posts/10157411734091411 .

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Sex Education – How to go about it?

Though we all want our kids to be safe, the moment someone mentions Sex Education, we shrink into a ball.Conventional sex education limits itself to half baked scientific knowledge of anatomy, pregnancy and sexually transmitted diseases.


This is still a Victorian model where ultimate aim is to drive people away from notion of sex by making it as uninteresting and scary as possible.
But erring on side of real knowledge, information about pleasure, eroticism etc brings you in conflict with law. And the biggest parental fear – if they know about all this, they WILL start using this knowledge.!Fair enough.


So in real life most kids learn about sex from friends and sex videos aka pornography.
Watching pornography as an adult has its own problems when you don’t know how to handle the emotional high jack of your brain. How terrible it must be for child’s or an adolescents brain to remain sane offer watching porn !


So here i am going to give you step by step “how to” about sex education.
First part is about Sex Education sessions in school and Second is about Sex Education at home.
Both parts are needed for complete cover.


Part 1 – Sex Education in School –

Most ideal way for this is to designate a teacher for this job. A teacher who is comfortable with biology and does not look skywards when taking about sex. This teacher should conduct sessions as ongoing activity as a part of life skill exercises. She can be available for trouble shooting when kids have queries that need private and confidential audience of a sensible adult.
Most schools do not agree to do this due to whatever reasons. They prefer an “outsider” to do the dirty job in a single session.
Rest all boring subjects are taught five times a week for ten years!And this most useful and 100% practical subject gets one miserable hour in entire 10 years of school. Beat that!
When I am invited for this job, this is how I go about it –
Simple rules –

  1. Boys should have a male facilitator for this session and girls a female facilitator
  2. Sessions should be conducted in sex segregated groups
  3. Single age group kids are preferred.
  4. 30-50 kids in a group is okay.
  5. 7th std is a good time for first session.

This session is for kids only so no staff member is allowed in the room. (Teachers and principal almost die of curiosity at this stage but I am a tough nut and I don’t crack under their pressure.) Once I walked out of a school when Principal refused to go out of that room.I get them all (boys only because I am male) in a classroom or meeting room and tell them that this is a confidential “ask me anything about sex” session.
I give them each one piece of paper.Ask them to write ONE most important/burning question they have about sex on that chit. They are instructed NOT to write their name. Question should be written in capital letters to avoid identification of handwriting.
All those chits are put into a donation box that I circulate in the group. I take a few minutes to read all the chits and segregate them in topic specific bunches and to check for any surprise questions. ( After 20 years of doing this, there are still a few surprises in every session)
Almost all questions are  –

  1. When can we start having sex and when does it stop
  2. How frequently should we have sex
  3. Homosexuality and other variations
  4. Size of penis (evergreen query!)
  5. Positions 
  6. Menstruation
  7. What turns women “on” 
  8. Contraception
  9. Rape
  10. Child abuse
  11. Porn
  12. Hygiene – body odour, etc.
  13. Masturbation (another evergreen query)

I read questions on each topic together and then give a scientific answers.
I always talk to them about few VITALLY important things –

  1. Consent
  2. Virtual world of porn and how disconnected it is from real sex
  3. Child sex abuse and ways to be safe (www.nobadtouch.com)
  4. Prevention of Sexual Offences Against Children Act (POCSO) – ALL sexual activity under 18 years of age is PUNISHABLE in india. Most kids and their parents are blissfully unaware of the law of land.

Some questions should not be answered if it requires inappropriate language in the answer as POCSO law penalises such conversations between and adult and child. E.g. one child wanted to know best way to pleasure a woman. (I tell them clearly why I will not answer that question, about POCSO and consent in simple language) They will have to wait for 18th birthday for the answer from me. 
I have been conducting these sessions in schools since last 20 years. They are full of giggles of relief and high fives because children feel really empowered with knowledge and actual experience of non judgemental Q&A session.
One huge relief for kids is that nearly all of them are struggling with same questions about themselves! Realizing universality of their anxiety itself is normalizing experience. It prevents many anxious , self occupied moments for them.
We ceremonially tear off all those chits at the end of the session and once again assuring confidentiality, i walk away. (I don’t ask them their names at any point in the session, i tell them about it right in the beginning)
Feedbacks about these sessions are consistently and overwhelmingly positive. I really wish schools do such sessions every six months with help of staff for std 7,8,9 and 10.


I will write a continuation of this thread about how to go ab