1. What is the significance of adolescent mental health? Why do we as a nation, have to look after our youth? And are we doing enough?

With 358 million people, adolescents aged 10-24 constitute about one-third of India’s population. They are an important part of our population and we must work with them, and for them. Adolescence is the one of the most vibrant and dynamic stage within the life course of a human being. At the same time, it is also a period of transition.

Their needs are different from children and adults yet until recently they were not even treated as a unique group. They have a wide spectrum of needs ranging from coming to terms with physical changes, dealing with social expectations, emotional turmoil, and to top it having to make major career and life decisions. Dealing with all these varied needs becomes more difficult when they are faced with challenges like unsafe environments, poverty and abuse. Hence the emotional needs are high and often lead to stress. If they do not have the required support, stress can get worse and that is why adolescent mental health is very important and deserves urgent attention

I think in recent times there has been a shift in policies and practice, and we are beginning to emphasise and look at this group with its unique needs separately. The government has initiated multiple programmes like the Rashtriya Kishor Swasthya Karyakram (RKSK) and there has been a shift in the narrative. Unfortunately, multiple stakeholders continue to work in silos when it comes to implementation of programmes. There is a need to work together and ensure convergence for better results and ensuring rights of adolescents to a secure and healthy future. 

2. As early as in 2003, you have voiced your concerns over adolescent health services in your paper “Sex, Studies or Strife? What to Integrate in Adolescent Health Services?” Which of these three aspects is more relevant to mental health among adolescents?  

All adolescent needs are important. The need of the hour is to ensure access to integrated services. India needs large scale promotional programmes to provide access to adolescents to build their skills, manage education and careers and train themselves to cope with any adversity. This includes a special attention to the most vulnerable sections as well eg: conflict ridden environments where there is a need to create outreach and support through the programmes. 

3. UDAYA studies in Bihar and Uttar Pradesh have revealed that a significant portion of adolescents in both the states show symptoms of depression, due to a host of reasons such as family poverty, education, domestic violence, illness etc… In this context, how do we bring about multicomponent interventions, rather than sticking to a biomedical approach alone?

I have a different view about the UDAYA findings. When we use surveys, we utilize screening tools and results can often be misunderstood. Many of the statements used in screening instruments are subjective and have a high possibility of being misinterpreted. Having said that it is no surprise that adolescents facing adverse situations such as domestic violence, illness or poverty are more prone to depressive symptoms. 

I think the way forward is to understand that mental health problems lie along a continuum from feeling distressed to having a clinical disorder and majority of people move along this continuum. As per my understanding the entire approach to mental health needs to change. To begin with we need to stop thinking of adolescence as the problem-age that needs fixing. We need to approach their mental health needs using a strength-based approach. 

We also need to explore alternate approaches that encourage adolescents to support each other, to recognize signs of distress in themselves and others and to be able to understand when to seek professional help.  What would really help is to bring in a narrative around mental wellbeing, to make adults aware of the importance of supporting adolescents with their diverse needs, instead of pressurizing them to live by their own expectations. It is important to create an environment where adolescents feel free to express themselves and be themselves. 

An example of an interesting program was AEP+, a programme that was initiated in Navodaya Schools through NCERT and UNFPA and implemented by St. Johns Research Group, Bangalore. In this programme a group of teachers within each residential school setting were trained to actively create an enabling environment for students. They encouraged students to talk to them when distressed and were trained to refer students only if the problems were severe and needed individual attention. Activities in the programme also included group support and in schools where the trained teachers could implement the programme well, very few adolescents had to go for individual counselling or needed professional help.

4. In the same study, on being asked for their reasons for feeling depressed, most of the adolescents pointed to pressure from schooling. In this context, what role can schools, and teachers, play in the mental wellbeing of adolescents?

As I said earlier in my understanding, there is a need to create awareness in schools and communities around mental health using a wellbeing approach. It is critical for parents and families to understand how they might be pressurizing the adolescents- contributing to a rise in mental disorders and depression.

5. Family poverty and domestic violence were two other major reasons for depressive symptoms among adolescents. What role can parents, and the community in general, play in preventing this? Any field experience you would like to share with us.

I would like to give a different example. My organisation develops, implements and evaluates programmes on building personal resilience. We have done a pilot project with Self-Help Groups (SHGs) in Bihar, funded by the Bill and Melinda Gates Foundation. In this project we used a strength-based approach and looked at feasibility and acceptability with illiterate women, who were a part of the SHGs. When we started the project, we received feedback that these women will not understand the concept of resilience and related skills. We discovered that the most common problem amongst the women was violence and poverty. Using our strengths-based approach we taught the women skills that helped them recognize their strengths, become aware of their emotions, manage conflicts and solve problems collectively. With the right skills the women were able to find solutions and take actions. This is a good example of how one can use this framework and help adolescent deal with adverse situations. 

6. As a practitioner with considerable experience in field research, what are the challenges you have faced in working on adolescent health in India?

I think with field research the biggest challenge I faced has been the high rate of attrition and dropouts. The adolescent population is continuously moving and in longitudinal research design, numbers change and often reduce over time. The second challenge is making the respondents understand the questions, especially in rural areas, one needs to put a lot of efforts to maintain the rigour that is required in good research.  

7. Take us through your current work at CorStone India. What are the areas you are focussing on?

At CorStone we work in government schools and Kasturba Gandhi Balika Vidyalaya – we have been developing, implementing and evaluating a programme that builds personal resilience. The programme has its roots in the field of positive psychology, social emotional learning and restorative practices. 

We began with small feasibility pilots in 2009 followed by an effectiveness trial and after a couple of years doing implementation science, we have now signed an MOU with the Government of Bihar to demonstrate how the programme can scale up across the state. Although we have been implementing smaller projects in other states through partners we are directly implementing only in Bihar at present.  

We also work in Kenya and plan to expand across other states in India and other countries across the world in the next few years. 

8. Finally, what according to you is the way forward in dealing with the problem of adolescent health in India, adolescent mental health?

I want to reassert the point that we must change the narrative around mental health in India. Let us focus on protective factors and strategies to create an enabling environment and adopt an integrated approach to adolescent health.