Dr. Arun Raj Kuwar is a child and adolescent psychiatrist in Nepal. He is the first child psychiatrist in the country and heads the Child and Adolescence Psychiatry Unit at Kanti Children's Hospital in Maharajgunj. Dr. Arun earned his MD in Adult and General Psychiatry in 2003 and completed a fellowship in Child and Adolescent Psychiatry at SUNY Upstate Medical University at Syracuse in New York. He was fulltime Research Assistant Professor at SUNY (2005 to 2009) and was awarded 'The Pilot Research Award'' by American Academy of Child and Adolescent Psychiatry in 2005 and 'Young Investigator Award' by National Alliance for Research in Schizophrenia and Affective Disorders (NARSAD) in 2008.

After he returned to Nepal in 2009, he joined the only 'one half day a week' Children and Adolescence Psychiatry (CAP) clinic, which hardly catered to the needs of about fifty children and adolescence in a year. In collaboration with the Government of Nepal's Kanti Children's Hospital, he established a fulltime CAP outpatient clinic which saw more than 12000 patients last year. Recently, he has expanded these services to Lagankhel Mental Hospital where there is a new in-patient psychiatric ward just for children with a capacity of 12 beds. This is the first of its kind in the country. Dr. Kunwar has also established the first and only Suicide Helpline of Nepal, which provides counselling and support to people who are having thoughts about suicide.

During an interview led by Anushka Regmi, Dr Kunwar revealed that the global statistics about 1 in every 5 children or young people suffering from some sort of emotional or psychological problem holds true for Nepal as well. He finds the increased investment of the Nepal government in mental health as promising, but pointed out how resources are limited and the number of cases of children under 18 are spiking. Excerpts:

What is child mental health, and why is it so important?

Just as with adults, children experience a range of feelings, including loneliness and anger. When these emotions persist for a long time, it can impact their mood and behavior, impeding their ability to remain joyful. Such emotional and psychological issues that disrupt the social well-being of young individuals is what constitutes child mental health. When children grapple with mental health problems, it affects family dynamics, hinders learning in school, compromises peer relationships and causes other significant distress.

All children and adolescents with mental health issues must be provided with essential tools, skills, therapies, and when necessary, medications. Nepal is a country with the highest rate of suicides among adolescence is the South-Asia region. According to the 2020 National Mental Health Survey, seven in 1,000 adolescents have attempted suicide in their lifetimes, and about 10 percent of children grapple with emotional or behavioral problems. However, contrary to the WHO recommendation of one health worker per 10,000 population, we have only 0.17 psychiatrists, 0.03 psychologists and 0.21 mental health specialized nurses per 100,000 people.

How does family behaviour affect the mental health of children, and what are the early signs?

A family's behavior significantly influences a child's mental health, serving as a crucial factor in shaping their overall well-being. Providing love and care and fostering the development of essential social and emotional skills in children during childhood often leads to a healthy and happy life. As for adolescence, they naturally seek new experiences, and should be granted the opportunity to explore within safe limits. As parents, our role is to encourage them to make wise choices and prioritize their safety, maintaining an open line of communication so that they feel comfortable seeking assistance when needed. Half of the mental health conditions in Nepal start as early as 14 years of age, and many of these symptoms go unnoticed and untreated. It is often small events such as separation from a family member or new situations in school that trigger mental stress in young children. While all children can feel anxious at times, feeling too sad or too anxious or having major disruptions in eating and sleeping patterns is a prominent sign of mental stress. For example, if a child who normally devours food is pushing food around their plate, we should take it as a red flag. Likewise, if a child is having frequent nightmares, if they stop socializing with friends, or if they are into excessive gaming, we should make a note that something is amiss.

Where should parents seek help when their children experience mental health issues?

In Nepal, there are several places where children and adolescents with mental health issues can seek assistance. The Child and Adolescent Psychiatry Unit at Kanti Children's Hospital decade is one of them. Established by the government of Nepal together with support from the children's organization Child Workers in Nepal's Concern Centre (CWIN), in collaboration with FORUT-Norway and the Norwegian Psychiatric Association, the hospital runs out-patient services and provides counseling to individuals. Recently, these services have been extended to Lagankhel Mental Hospital as well. We have also started a new in-patient psychiatric ward just for children with a capacity of 12 beds. This is the first of its kind in the country.

Other than that, parents can also utilize the recently introduced 'ma chu ni' chatbot (Tele Mental Health on Facebook). This chatbot, accessible via mobile phones, aims to understand users' needs and provides advice on managing stress and coping with various situations. In cases where direct interaction with a counselor is necessary, those that are using the chatbot will be referred to a tele-mental health OPD service located at Kanti Children's Hospital. This service facilitates direct contact with a counselor to address mental health concerns. If these options are not feasible, it is advisable to visit a pediatrician or a psychiatrist at the nearest hospital to receive insights and guidance tailored to the children's specific needs.

What are the main challenges in this sector?

According to the 2022 report prepared by the WHO Special Initiative for Mental Health, the Government of Nepal has been gradually increasing its political commitment to mental health services in recent years. However, we continue to witness a significant surge in the numbers of patients, from 600 initially in 2015 to 9,000 last year, with projections indicating a further increase to 12,000 this year. Several challenges, continue to impede the development of the mental health sector, including the deep-rooted perception in Nepali society that mental illness is fundamentally different from physical ailments is one of them. In many parts of the country, mental health issues are still attributed to spirit possession, black magic, or actions in previous lives. Also, it is often the faith healers who are the first point of contact for individuals experiencing mental health challenges. Another significant obstacle is the lack of recognition of child mental health as a priority that requires attention and improvement. Consequently, both the general public and the government tend to overlook this critical issue, resulting in insufficient allocated funds and a shortage of human resources in the sector. Compounding the problem is a pervasive stigma surrounding mental health, hindering open discussion and prompting skepticism about seeking help. This deep-seated stigma often leads individuals to believe that psychiatric assistance should only be sought in dire circumstances, delaying timely diagnosis and intervention. Addressing these multifaceted challenges is crucial to advancing the state of child mental health in Nepal.

Should we be worried about the current situation?

Absolutely! The current situation warrants significant concern. A major challenge affecting 33 percent of Nepal's population under the age of 18 is the prevailing issue of mental health. And, it is disheartening to note that the young demography that we are reaching out to represents less than 1 percent of the total population in need of assistance. This underscores the urgent need for comprehensive measures to address the escalating challenges in child mental health across Nepal.

According to the World Health Organization, Nepal is a country with the highest suicide rates among adolescents -which constitute 40 percent of the total population. According to the various surveys, seven in 1,000 adolescents have attempted suicide in their lifetimes, and about 10 percent of children grapple with emotional or behavioral problems. Despite these alarming figures, timely treatment for mental health issues remains elusive for various reasons, including a lack of awareness about mental health and an insufficient number of mental health services and trained professionals, many of whom are concentrated in urban areas.

A bright side to this is the way younger generations today are opening up about their mental health issues, even discussing them with friends and family members. That is the first step towards a sound mental health.

So doctor, looking ahead, is there light at the other end of the tunnel?

At the current juncture, it is unfortunate that we are all inside a long dark tunnel. To reach the end, it is important for all to keep our eyes and minds, as well as our hopes and dreams, focused on the road ahead. The first step on this is to accept the enormity of the challenges and accept mental health as a serious concern.

As Robert Frost aptly noted, 'The best way out is always through.' There are no quick fixes, and the path ahead may be lengthy, but there is no alternative – we must persevere in addressing these challenges in the mental health sector for the well-being of our children.

Anushka is interning for the Child Workers in Nepal Concerned Centre (CWIN) –which is a children's organization that runs a child helpline and rescues children living and working in dire conditions across the country.