Straying into child psychiatry, Dr. Diyanath Samarasinghe

Early (JVP) days

The insanely vicious activities of the JVP forced me, long years ago, to stray into child psychiatry – not in a clinical practice but outside. Hiranthi Wijemanna of UNICEF untiring worker for children asked me how we could help large numbers of children traumatized beyond belief in those times, with little access to even the most basic services. The example was a child from the south, who was mute from the da her father was shot outside their village home.

Hiranthi asked how we help could organize help for such a far way child in desperate misery.  “The midwife is the only resource, Diyanath. You psychiatrists are all in Colombo and we can’t get all these poor children to travel for days to see you. In this child’s case, an armed JVP group had descended on their house in the night and demanded that the father come out. Others were told to stay silent and keep the lights out. The child had somehow found herself outside the house along with the father. The family heard gunshots and realized that the father had been shot. The child too had gone missing in hullabaloo. The family did not dare open the door to check – and perhaps assumed she may have been killed too. Next morning they found the body of slain man in the garden and a little later located the child, huddled behind a bush – and completely frozen mute. There are too many of these victims Diyanath, all over the country, so we have to find a way some how to reach them’. Or words to that effect.

Similar requests and horror stories led eventually to a few psychiatrists – Kalyana Rodrigo, Anula Nikapotha and I, and later Priyani Ratnayake – trying to organize practical help. For Dr. Rodrigo and me it meant helping children ‘in the field’ despite not being qualified to treat them in our clinics. We had as a result to ensure that our efforts did not risk the slightest harm. All our intervention models therefore included constant and vigorous efforts to examine impacts on the immediate, short and long term. To follow what happened to children being helped by our trainees – public Health Midwives (or PHMs), parents and community members – was easy, as the trainees were in regular touch with the children being helped, unlike those we see at specialist clinics.

Consolidation

These efforts with children were remarkably helpful. The genuineness of the helpers was probably the major ingredient, we provided models that allowed their innate wisdom and kindness to be used in ways that they could themselves evaluate. No ‘child psychiatry’ theory was ever taught. Understanding needs for optimal adjustment was the main entry. Families were then helped to assess the level of provision of each of these in the given child to analyze how the most limiting ones could better be provided. With children showing behavioral or emotional symptoms, a simple framework was also given, to help parents work out of the underlying causes or process leading to the symptom or behavior concerned and to address these. Changes in the hypothesized causes were also constantly assessed, not only the presenting difficulty. Interventions were all delivered through either PHMs, or other helpers that could be mustered. Sessions were mostly held in the relevant MOH office.
We could hardly believe the progress made by children and families helped by the ‘trainees’: all women. Diligent records were kept, as instructed, because they were enthused by the progress of the children and keen to get feedback regular training sessions. We learnt far more than they did.

Latter (LTTE) days

When the LTTE mayhem overshadowed that the JVP, calls were made similar interventions on either side of the line of conflict – but mostly with the children in Sinhala-peaking areas traumatized by nocturnal LTTE attacks. Trainings in Tamil-speaking areas did not extend beyond the Wanni region. In all of these, we found interventions for trauma of the highest possible degree could be delivered by people with the formal training of a PHM or less. And again we learnt much. Many children overcame problems that we felt would have taken highly trained specialists – such as – much longer to achieve.
Previous lessons were incorporated into formal training manuals and other documents used for dissemination, mostly by UNICEF Sri Lanka. And we worked hard at keeping an eye on how each child progressed. It was possible after a time to create groups that provided mutual support, training and supervision, with no specialist intervention. Some of these were supplemented by GCE- qualified outreach facilitators, to achieve greater coverage. The demand for, and documented impacts of these inventions were heartening.

Organizations such as ‘Nest’ and ‘Nivahana’ later took up some of the principles and helped disseminate them. Links were begun with several agencies in the North, such as Shanthiham in Jaffna, but not proceeded so far. Most of the spread was by interested personnel   in the public health sector or other agencies taking up the approach.
I am guilty of having failed to reach the mainstream psychiatry establishment. I suspect it was because it was because all the activities were centered on communities and not clinics, and were based on getting people to help themselves, with minimal resort to curative services. In my defense I could plead also that there were at the time no child psychiatry services to speak of, in the areas we had to work in. Even Adult psychiatry services were minimal.

Lessons

I am sure some of the lessons I state here will be dismissed as invalid, without a second thought, by those of contrary point of view. But I offer them anyhow, in good faith. I have tried to minimize subjectivity and bias in my retrospective conclusions from accidental forays into ‘child psychiatry’. These may not seem real to the real psychiatry of our clinics and hospitals. They are based on realities in rather different settings: where people live, work, laugh and cry.
(I’d be happy if any disagreements – or added insights – can be conveyed to me through samara-singhe@hotmail.com or simply by talking to me, about the lessons listed below.

Having secure, responsive relationships with caring and insightful adults (parent, parents or others) cures and prevents most childhood problems. Nearly all of the interventions for emotionally wounded children involved strengthening their parents or carers and then improving their ability to understand the child’s real difficulties. Psychiatry services may be guilty of destroying or suppressing these ‘naturally available’ human interventions through our tendency to professionalize help. Strengthening and guiding carers may be what is primarily needed for most children presenting to our services.

Very little of child psychiatry work needs to be ‘bio-medically’ based. Where we have physical remedies available for a given ‘condition’, we should guard against their first use as the best option. Train ourselves to do this, and we fail to notice that we could be taking an option that we have quietly been shaped into taking, despite there not being good enough evidence to support it. Our habitual option is the easiest one, so laziness has to be overcome if we are to remedy this problem.
When we learn of children improving with help from ‘ordinary people’ we should first question our assumptions before we dismiss these gains as false, inferior or temporary. Remarkable results achieved by our mothers and midwives were dismissed as superficial – by trauma expert who flew in after the peak of themselves, mostly called ‘counselors’, who managed through technical jargon and other artifices to invalidate the work of mothers, families and communities. We too many, impresses by our professional credentials, rob people of the power to help themselves.

Since a good part of ‘deep-seated emotional wounds’ resolved with no expert care, we should examine whether other child psychiatry ‘disorders’ too may do the same. When families and communities are given the confidence and the means to critically examine their progress, they may deal with a good part of PTSD, ADHD, conduct disorder and emotional disorder better than we do. The fear that we may only be left with autism and learning disability to deal with, should not deter us from continually reducing the number of children labelled with these purely syndromely–validated conditions.
Learning to be child-centres in our treatment is not only kind but also efficient. In most successful interventions of our PHMs and mothers, the primary ingredient was learning to understand and respond humanely to the needs and feelings of the child. If this course is followed with other conditions – such as school refusal or bedwetting – we may get better results and with less trauma to the child victim. (Imagine the equivalent strategy that is used for school-refusal being applied to an adult who is labelled to have ‘office-Refusal’ disorder.)