Mental health needs of children and adolescents in child care institutions in Sri Lanka

Background The number of children placed in institutional settings around the world is rapidly increasing due to factors like poverty, war, violence and substance use. Bringing up children in childcare institutions can deleteriously affect their development due to profound deprivation of sensory, linguistic, cognitive, emotional and psycho-social stimulation. According to the United Nations Children’s Fund (UNICEF) report in 2009, up to eight million children are in institutions worldwide. However true figures may be higher due to gaps in global statistics and unregistered children’s homes.

In Sri Lanka, institutionalized children are more stigmatized by society, thereby encountering problems when trying to adjust to life outside the institution. This may be due to segregation within institutions limiting contact with family, community and other children. Institutional care also provides limited physical care and limited effective responses to their psychological needs 9 .

Mental health related issues in children and adolescents in childcare institutions
Worldwide research has shown that mental health of institutionalized children is significantly worse than their peers, nearly 50% fulfilling criteria for mental illness 10 . Children under care experience more adverse physical, mental health, educational and social outcomes 11 . According to a United Kingdom study, youth leaving care have 5 times higher risk of suicide than the normal population and a greater likelihood of entering the criminal environment 12 . Aetiological factors for mental health issues can be events prior to institutionalization, events related to process of institutionalization, events after institutionalization and events after deinstitutionalization.

Psychological impact on children due to prior events / factors which resulted in institutionalization
 Poverty can negatively impact the mental health of children. Children with poverty can experience deficiencies in nutritious food, housing, safe environment and access to health care and are at higher risk of being exposed to trauma and stressful life events like parental separation, domestic violence, and punitive parenting practices. Poverty can also lead to social isolation and marginalization 7 . Empirical evidence has shown heightened baseline activation of the stress response system in poor children due to chronic stress exposure 7 .  Children with learning disabilities are at six times higher risk of getting a diagnosable psychiatric illness such as depression, anxiety or psychotic disorder which can be further increased by exposure to traumatic events like separation from home due to institutionalization 13 .  Children with chronic physical illnesses can experience more behavioural and emotional problems than children with good physical health even before institutionalization and their risk of a major psychiatric disorder is also high 14 . Major depressive disorder and chronic medical disorders are strongly associated 15 .  Child abuse victims can experience a wide range of psychological consequences which can be short-term effects (in childhood) and long-term effects (in adult life) 16 19 .

Psychological impact due to events occurring during the process of institutionalization
The process of institutionalization itself is stressful for children due to a variety of reasons. Once a child is victimized for an abuse he or she will be interviewed by different stakeholders from different professions including health care workers, police, legal system, probation and social service. National Guideline for Management of Child Abuse and Neglect: Multi-sectoral Approach in Sri Lanka, has given clear instructions on responsibilities of different stake holders when dealing with victims with minimal re-traumatization 20 . However, it is evident that during this process, victims are retraumatized by stakeholders due to many reasons which can result in adverse psychological consequences among victims 21 . In situations where the perpetrator is a family member, victims may have non-rational guilt towards him or her 22 .

Psychological impact on children and adolescents after institutionalization
When a child is institutionalized, his or her opportunity to have contacts with the family becomes limited. Some institutions in Sri Lanka only allow family to visit the child once a month.
The psychological impact on the child of separation from the family is determined by the age of separation, attachment with family, nature of care received at home, level of security felt at home, level of support received at the institution and duration of stay at the institution.
According to the attachment theory put forward by John Bowlby, a British child psychiatrist and psychoanalyst , "The earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life". Thus, mothers who are available and responsive to their infant's needs establish a sense of security in their infants. Bowlby also identified the first three years of life as a very sensitive period for attachments 23 . As mentioned in Bowlby's attachment theory, studies showed that children institutionalized before the age of three can experience difficulties in formation of emotional attachments which can negatively affect their social behaviour and interactions with others 24 . They can also experience poor cognitive development and language deficits 24 .
Many studies have found that social deprivation and neglect at institutions can greatly increase the negative psychological impact on children like developmental delay and mental health disorders 11 . Young children with a history of institutional care often show behavioural and emotional problems such as hyperactivity, poor attention, emotional dysregulation, increased anxiety, attachment disorders, and poor peer relationships 11 . Same study showed that institutionalized children can have more internalizing symptoms, like anxiety and depressive disorders and externalizing symptoms, like attention-deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder. Their functional level was also found to be lower than controlled group 11 .
Institutions are not necessarily good environments for children. Children in institutions often experience "structural neglect" including minimal physical resources, unfavourable and unstable staffing patterns and social, emotionally inadequate caregiver-child interactions 25  Even though well-structured national policies and action plans are in place in Sri Lanka, it is evident that the quality of care the children receive at institutions is not optimal. Here are some clinical examples of children and adolescents who presented to child and adolescent psychiatry units.

Case 1
Mr S was a 20 year old boy studying in a government university. He had been in an institution from age 1 to 18 years. He did not know about his biological family. He presented with clinical features of social anxiety disorder where he was unable to perform academic presentations at the University in front of other people. This has significantly affected his academic performance in the university. On assessment, he presented with exceptionally poor self-esteem, self-confidence and negative self-evaluation, which were the main aetiological factors for his clinical presentation. He explained how his self-esteem was badly damaged during his stay at the institution where people repeatedly called him "anathaya" (orphan in Sinhala). He also explained how he felt worthless and useless about himself when he had to deliver "pin" (a religious way of showing gratitude) after each meal.
Society commonly stigmatizes children in institutions as orphans. Most people also believe that these children can be used as objects for their charity work. In modern society, people commonly donate things to these children, taking pictures and posting them in social media. Zero measures are taken to maintain the dignity and confidentiality of youth. Majority ignore or are unaware about the impact of their behaviour on the psychological wellbeing of these children. United Nations convention of the rights of children article 39 emphasizes the importance of self-respect and dignity of children when dealing with child victims. It is also important to focus on the legal and ethical aspects of taking pictures of these children without the consent of guardians or responsible state parties.

Case 2
Miss M was a 16 year old girl living in an institution for 2 years after sexual assault by her stepfather. She presented to the child psychiatry unit with clinical features of depression. On assessment, she reported that she was repeatedly accused by the main caregiver at the institution saying "I am still a virgin, not like you". Even a minor mistake at the care home ended up with the same conversation. She reported how this repeated statement traumatized her at the institution.
Child maltreatment at institutions is common worldwide. Caregivers' frustration due to limited facilities, knowledge and training at institutions about caregiving, counselling and handling difficult situations may be the main contributory factors.

Case 3
Three fifteen year old girls were brought to the child psychiatry unit for assessment from a child care institution. One girl had cut her hair and started behaving as a male, identifying herself as "Sanjeewa" (male name). Other two girls had started a romantic affair with "Sanjeewa". On assessment, the girl, behaving as "Sanjeewa" was not having clinical features of gender identity disorder. All three girls presented with predominant heterosexual orientation. Main reasons for their behaviour were limited access to the outside world, limited access to the opposite sex, lack of pleasurable activities at institution and not having future goals and meaning to life.
Residents having sexual contacts with other residents of the same sex is common in child care institutions worldwide. In most circumstances it is not due to clear homosexual orientation. Age appropriate sex education, introducing structured environment and leisure activities at institutions and making them understand future plans and goals would help minimize these incidents.

Challenges as adults after deinstitutionalization
Childhood abuse victimization can result in low selfesteem, self-confidence and problems in interpersonal relationships even as adults.
According to the concept of "Circle of abuse" children who were abused as children can become abusers as adults. Their self-esteem, self-confidence and self-evaluation can be badly damaged in institutions. Due to limited access and experience with the outside world and social deprivation they can have difficulties in getting adjusted to the outside world as adults. When they do not have their own families in the outside world they are more prone to build up social connections which can make them more vulnerable to get connected to unhealthy social groups such as substance use and sexual exploitation.

Things can be done at institutions in Sri Lanka to support mental health needs
Children and youth in institutions have higher need for mental health services worldwide compared to general youth 29,30 . However, relative to their high rate of mental health needs, service utilization by them seems low. Furthermore, a considerable part of this population does not receive services according to need 31,32 . Developed countries have established community based child and youth mental health services providing separate services for children in institutions.
Currently in Sri Lanka, child and youth mental health services are at a primitive stage with very limited numbers of child and adolescent psychiatrists. Current services in Sri Lanka are mainly hospital-based and community-based child and youth mental health services are unlikely to be established in the near future. Considering the huge mental health needs of children in child care institutions it is vital to pay more attention to this aspect.
Alternative child care policy in Sri Lanka has clearly identified the areas to improve in providing best quality care for children in institutions while adhering to all the principles of United Nations for Convention of the Rights of Children 1989 2 . However, most of the plans are still at paper work level. Before focusing on comprehensive community-based child and youth mental health services in Sri Lanka, it is crucial to focus on fulfilling the basic mental health needs of these young people with the limited resources available.
This can be approached in three areas. There should be staff focused programmes, residents focused programmes and institution based programmes. All caregivers in institutions should be given continuous training and support on how to provide care for these children with minimum further traumatization, how to handle difficult situations with children, problem solving counselling and how to provide psychological support for these children.
Simultaneously, programmes should be conducted for youth focusing on how to improve social skills, communication skills, problem solving skills, anger management techniques, emotion regulation and distress tolerance skills, assertiveness skills and life skills. Structure of the institution also has to be improved in a way where youth get more structured and effective routine, more leisure activities, more opportunities in vocational training and activities of daily living training. All these activities should finally target the smooth and less disturbed systematic deinstitutionalization of youth.