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Children in Mind : Their mental health in today’s world and what we can do to help them

Are today’s children and teenagers more mentally distressed than they used to be, and if so, why? What is it about today’s world that seems not well suited to children? Children in Mind (Wits University Press) tries to address these three important questions.

The developing minds of children are strongly influenced by the environment in which they are being raised. This environmental context includes family, home and school life, socio-economic conditions, race, geographical location, civil unrest, crime and circumstances that arise out of politics and governance. The modern world is digital, mobile, fast-paced and politically unstable. We are faced with ongoing, often life-threatening crises, including the global COVID-19 pandemic, other health threats like HIV, and climate change with its associated environmental concerns. There is a wide gap between rich and poor, with huge challenges for children who grow up in poverty. Some children live an isolated, sedentary lifestyle, virtually plugged in but physically disconnected from others and from their own bodies, from nature and the outdoors.

A wide range of recent neuro-biological, epidemiological, psychological, psychiatric and other research has revealed some interesting findings about why some of today’s children might be more stressed and unhappy than they used to be. The findings depend on which children are being examined under what circumstances, in what areas and by whom. It also depends on the extent to which mental health is understood and acknowledged in the child’s family, school and broader community, the attitude towards children and whether or not the adults in that child’s world notice how the child is feeling and behaving. Interpretations of and attitudes towards childhood mental distress determine how adults in children’s lives respond to their behavioural and emotional problems.

Changes in childhood psychiatric diagnostic classification
Certain childhood psychiatric disorders are more prevalent now than they used to be – although much of this is probably linked to better access to and utilization of mental health facilities and changes in diagnostic labelling processes amongst mental health practitioners. For example, Attention Deficit Hyperactivity Disorder (ADHD) can be over-diagnosed and over-medicated, although sometimes this diagnosis and treatment approach is the most appropriate and necessary course of action, in the best interests of the child. Epidemiological research done in 2020 by Lorna Wing and David potter suggests that whilst the prevalence of Autism used to be approximately 2 – 4 per 10 000 children, it is now approximately 60 per 10 000 children. The authors explain this dramatic rise in incidence as a result of changes in diagnostic criteria, raised awareness and more recognition of Autism Spectrum Disorder (ASD).

Psychiatric diagnostic labelling in children is a hotly debated issue and not everyone believes in it. But to be fair, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is constantly being revised, adjusted and updated according to an ever-changing world. Psychiatric diagnostic classification is a human construct. There is, for example, heated debate about what is classified in the International Classification of Diseases (ICD-10) as Gender Identity Disorder under the category Mental and Behavioural Disorders. Much controversy has surrounded this because of the unacceptable pathologisation of variant gender. Thankfully, in the updated and revised ICD-11, adjustments have been made and Gender Incongruence falls under Conditions related to Sexual Health rather than Mental and Behavioural or Neurodevelopmental Disorders. Gender Incongruence is defined as marked and consistent incongruence between an individual’s experienced gender and the assigned sex. According to researchers such as Kaltiala-Heino, the prevailing ideology today amongst mental health professionals is that gender presentations are fluid and changing over time and that gender variant children need to be allowed to freely explore a range of gender identifications and expressions. Arguably, today’s world might actually sometimes accommodate better for certain individuals than it has done in the past.

Poverty, early trauma and toxic stress
Harvard professor of psychology, Steven Pinker, believes that the modern world is generally less harsh and more hospitable than it has ever been, especially for children. He writes that it is no longer socially acceptable or legal in many parts of the world to treat children badly or to force them into hard labour. Children’s rights are taken more seriously now than before. Research done by Franziska Reiss in 2013 has shown that children who are growing up in poverty are two to three times more likely to develop mental health problems. Early toxic stress and adverse experiences during childhood are known to have a dramatic impact on mental health and sometimes physical health too. These negative effects of hardship and abuse during childhood can persist into adulthood. The groundbreaking research done by Vincent Felitti and colleagues in 1998, commonly known as the ACES study (adverse childhood experiences), provides evidence of the link between adverse childhood experiences and future health risk behaviours and diseases, both mental and physical. For children living in contexts marked by adversity, Xanthe Hunt and Mark Tomlinson have described a developmental cascade leading to numerous negative developmental outcomes. Poor functioning in one area of development early in life can spill over to influence other domains of development which can in turn impact on subsequent development in other areas of functioning. But it is not only children who have suffered trauma, early adversity, toxic stress or socio-economic hardship who are mentally distressed. It appears that children living in relatively easy environments with no or few risk factors also often suffer from mental health problems.

Screens, the internet and digital technology
The internet and digital technology are a mixed blessing for today’s children. They are crucial and highly beneficial for education, communication, connection and everyday functioning in the modern world, especially during the COVID-19 pandemic. But balance is important and limits for screen-time are essential because of the other developmental tasks that need to be achieved away from screens. Most parents are acutely aware of the addictive power of screens and the unspeakable rages that children can fly into when they are separated from their screens. Researchers such as Twenge and Campbell have found that the more time children and teenagers spend in front of a screen, the less psychologically healthy and more emotionally dysregulated they appear to be. Adolescents who use screens a lot are more likely to be depressed and anxious. Children don’t only develop mental health problems because of the over-use of screens, they also use screens in order to try to cope with their own mental distress. Their parents sometimes also use screens as a kind of a pacifier to help distressed children to regulate their emotions and calm down. Digital technology and screens can provide parents with a much needed break from the relentless demands of caring for an emotionally and behaviourally disturbed child. Immersing themselves in their digital devices is just one of the many strategies that children use in order to try to feel better when they are stressed, agitated and unhappy.

Adapting to the environment and defense mechanisms
One of the things I love about children is how hard they try to be happy and adapt to difficult situations in which they find themselves. Sometimes they look happy to outsiders and they can even appear to their parents as though they are untroubled by realistic stress, trauma and losses. In Children in Mind, I describe some of the defense mechanisms that children often use to hide their sad, vulnerable and scared feelings – even from themselves. Their mental distress is sometimes revealed only in their behavioural symptoms, largely out of their own conscious awareness and out of sight from their parents, teachers and everyone else in their lives. Graham Music describes the ways in which defense mechanisms start off as adaptive strategies to cope with difficult experiences. The adaptiveness falls away as the environment is no longer persecutory. Often those defense mechanisms persist into adult life. It is one of the many reasons that early psychological intervention with children and families can be so helpful, as opposed to addressing mental problems in adulthood, once the defenses have been established and interwoven through the trajectory of development. The escape into various forms of addiction, in an attempt to avoid stress and a troubled, unquiet mind, is just one example of defensive behavioural patterns that have persisted into adulthood.

The researchers, Tallandini and Taudek, have suggested that the number of defenses used decreases with age and that defenses are used more by children who adjust less easily to new environments and those who are less outgoing towards others. Excessive use of defense mechanisms is an indication of psychological difficulties. In circumstances of ongoing stress, abuse and trauma, it may not be wise or therapeutic to pathologise children’s defense mechanisms or their behaviour. Psychologists Gillian Eagle and Debra Kaminer have discussed children growing up in dangerous circumstances with multiple prior exposures to traumatic stress and the ways in which their preoccupation might be on how to avoid danger and find safety. The challenge for these children is to discriminate between real threats, benign ones or imagined ones. In order to function optimally in dangerous or violent environments, certain adaptive strategies (defenses) might be realistically required – including paranoia, hatred and the desire for revenge.

The genetic link between nature and nurture
Recent research into the link between genetics and psychopathology provides more clarity on the fascinating interface between nature and nurture. Jay Belsky and Michael Pluess have discovered that some people are genetically more susceptible and vulnerable to environmental influences – for better and for worse – and that those people who are more reactive to the adversity of the world around them are also more likely to benefit and respond favourably to therapeutic interventions. It is particularly relevant and important with regards to children because their developing minds are influenced by the environment. This genetic research is the basis of the popular orchid-dandelion metaphor. Orchid children tend to thrive when their outside world is ideal but they are particularly vulnerable – because of their genetically based neurobiology – to environmental stress. Dandelion children are less reactive to their environment, whether it is better or worse. Environmental stress appears to have increased substantially for many, but not all families as a result of the COVID-19 pandemic.

Child psychotherapy referrals have increased dramatically in certain areas over the past year. Children and their parents seem to be experiencing mental distress for a wide range of different reasons. Presenting symptoms are not the same for each child. Anxiety about COVID-19, illness and other factors associated with loss and grief (because of COVID-related deaths) are not the only areas of suffering for these children. Factors associated with the pandemic can include financial stress, increasing poverty, and rising unemployment. This kind of stress can sometimes lead to destructive family relationships, addictions and an increase in parental psychopathology. Children experienced the harder lockdowns differently, depending on the atmosphere in the lockdown home and other circumstances. Some lockdown homes have been violent and toxic with high levels of conflict. Others have been supportive, relaxing and interpersonally satisfying. COVID-19 has been stressful and traumatic, but not for everyone.

There is substantial variability in each person’s experience of the pandemic. Some children have benefitted from reduced social and scholastic demands and commitments. Others have felt isolated and alone. Some children have experienced trauma and loss as a result of COVID-19 related family illness and death. Perhaps more widespread has been the obstacle to development when schooling and normal life were put on hold, sometimes for some children for an extended period of time. Spending more time at home, away from school and other activities, seems to have contributed to psychological regression in some children. They appear to have become more dependent on their mothers, fathers or caregivers, and less able to separate from them in an age appropriate way. Lockdowns made it hard for some children to escape toxic family dysfunction, parental illness and substance abuse. Being trapped in a turbulent or emotionally tense home environment with no school, sports or outside hobbies and activities with friends was difficult for many children. Others became more withdrawn and they climbed further into their screens, away from the challenges of everyday life.

Modern family life
Modern families are proudly diverse and complex, sometimes involving donor eggs and sperm, assisted reproduction, same sex parents, single parent families and cross-race adoptions. There is not sufficient convincing evidence that any of these factors are necessarily directly linked to childhood mental distress, unless particular circumstances related to those factors bring stress, loss, trauma or suffering to the child. The loss of a biological parent can, however, be extremely traumatic for a child, as can the absence of one or both parents in a child’s life. High conflict divorce with adversarial battles between the parents can put severe stress on children, leaving them pulled and sometimes torn apart by warring parents.

Parenting today’s children
Today’s world seems to be very unforgiving of parents. There are high, conflicting demands on parents to raise their children in particular ways – often leading parents to feel persecutory guilt if their children are not perfect and problem-free. Parenting styles vary across cultures and generations. In many countries in today’s world, including South Africa, it is against the law to use any kind of physical punishment. Sometimes parents struggle to navigate limit-setting and discipline without resorting to violence. Growing up has probably always had its challenges and it might be that today’s children are less defended or less resilient because the world is generally less harsh. Human beings are notoriously difficult to live with, so family relationships are often complicated and even volatile. An intergenerational transmission of family dysfunction can occur across different areas of behaviour and within interpersonal relationships. This can be emotionally traumatic for children and for their parents as well.

In conclusion, sometimes, some children might be more disturbed because of various aspects of twenty-first century life. But there are also great benefits for modern children who are not facing adversity in its many different forms. Mental health is given more consideration now and there is increased public and professional awareness of its complexities and the necessity for treatment. Perhaps children seem more distressed nowadays because today’s adults are more likely to notice their distress, think about it, and try to help. That is exactly what Children in Mind has attempted to do. The book is available at most booksellers, both retail and academic.

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