In the consultation room, Li Ting's mother rolled up her daughter's sleeves, revealing more than a dozen knife marks on her two arms, of different shades. The day before the visit, Li Ting almost jumped from the 15th floor, and the family was terrified.
Li Ting had just turned 12 years old, with a handsome face and a red necklace around her neck. It is at her age that she cares a lot about her image. During the consultation, Li Ting half-bowed her head and didn't say a word, but stepped on her mother's feet from time to time. The family hopes that the doctor will arrange for her to be hospitalized as soon as possible.
Qi Junhui is the attending physician of the Department of Child and Adolescent Psychiatry at Beijing Anding Hospital, and this is not the first time she has met Li Ting. A week ago, her mother brought her here for the first time and told her that her daughter had been staying at home since June last year, and when she was in a bad mood, she would smash things, quarrel with her family, and even harm herself.
"Depressive state", this is Qi Junhui's initial diagnosis of Li Ting. Last time, she had suggested that Li Ting be hospitalized, but her mother did not agree. This time, Li Ting's idea of jumping off the building made her change her mind.
Qi Junhui immediately contacted her colleagues to give Tingting a hospitalization number, and she couldn't say how long she would have to wait. There are more than 80 beds in the pediatric general ward of Anding Hospital, which is full all year round, and nearly half of the residents are 10~16-year-old children with different degrees of depression.
In May 2021, the first survey report on the prevalence of mental disorders in children and adolescents in China was published in the journal Child Psychology and Psychiatry. The survey was launched at the end of 2012 and selected about 74,000 children and adolescents from five provinces (municipalities) of Beijing, Liaoning, Jiangsu, Hunan and Sichuan.
The survey results show that among 6~16-year-old school students, the total prevalence of mental disorders among children and adolescents is 17.5%, of which depressive disorders account for 3.2% and anxiety disorders account for 4.7%.
Zheng Yi, chief expert and chief doctor of child psychiatry at Beijing Anding Hospital affiliated to Capital Medical University, led the investigation. "Based on the number of students in China, this number is already very large, and the target of our survey at that time was school students, and it did not cover those children who could not go to school for various reasons, and if we counted them, the prevalence rate would be even higher. Zheng Yi said.
In his view, children's mental health problems have become a serious public health problem, and this cannot be solved by doctors, it requires the integration of family, school, medicine and society.
Teenagers: "All I have in my head is sad feelings"
When Li Ting was about to be hospitalized, Chen Rui had been living here for 18 days.
She sat on a chair in the verandah and said that she wanted to be cured, but she didn't really want to be cured, strictly speaking, she didn't dare to cure. "Most of my illness was due to family reasons. She said.
Chen Rui sat on a chair in the verandah and said that she wanted to be cured, but she didn't really want to be cured (issued by CCTV, photo provided by the interviewee)
Chen Rui, 14, is a native of Beijing, and her parents are "traditional" in her eyes: her father is short-tempered, preachy, typically machismo, and often speaks in a commanding tone. Her mother has a strict education, and she has enrolled in various cram schools since she was a child, and she has no free time even on weekends, so she can't help it if she doesn't want to go to school.
The environment at home made her feel depressed. Chen Rui felt that she began to have psychological problems when she was in the third or fourth grade. At that time, she was already able to get to the top of her class, but her mother would still scare her with the words "If you don't study well in elementary school, you won't go to high school". "She wanted me to be at the top of my grade, which I didn't think was possible, but she did. ”
The fuse was that after entering junior high school, a friend who had been friends for many years broke up with her. Some classmates took advantage of this to gossip, and her relationship with her classmates became strained, so that she wanted to "avoid these classmates". Later, her emotional problems became more and more serious, sometimes irritable, sometimes suddenly painful and sad, and on two occasions she couldn't control her crying when she went to class, "there was no sign at all, only sad feelings in her head".
Her body began to show abnormalities: sometimes her mind was confused and she couldn't hear the outside world, and sometimes she woke up and her vision was distorted, and it took half an hour for her to return to normal. She vomited a lot, and when she was so frequent, she had to get off the subway every stop to vomit. She later learned that this was a somatization symptom of a depressive state.
Naturally, academic performance is also declining. She had difficulty concentrating and could read the words on the blackboard, but she couldn't understand what the teacher was saying. My memory also became very poor, I ate at noon and forgot what I ate in the afternoon. Even, the idea of suicide began to flash, she would want to stab herself with a fruit knife, but she didn't dare, because she was reluctant to let go of the kitten at home. She would rather someone suddenly stab her on the street.
She told her mother that she was afraid she was suffering from depression. But my mother didn't believe it, because she compared the content of the middle school textbook about "puberty performance" and thought she was just in line. It wasn't until she cut her wrists with a knife and hit her head against the wall in order to be sober that her mother took her to see a doctor.
"Why do children do this?" is the question that most parents will ask when they see He Fan, either directly or tactfully. He Fan is the chief physician of the Department of Child Psychiatry of Anding Hospital, and often after some examination and explanation, she will tell her parents gently but seriously: because he is sick!
He Fan introduced that depressive disorder is an objective disease, just like people can break bones, not as many parents think: children become stupid, disobedient, lazy, or rebellious in adolescence.
In fact, she said, adolescent rebellion will have some emotional problems and oppositional disobedience, but it is all within acceptable limits, and it will not self-harm, suicide, loss of social functions such as schooling, etc. According to the results of epidemiological surveys, the prevalence of depressive disorders in children and adolescents is almost the same as that of adults, which is an international consensus.
Qi Junhui said that for teenagers, the age of 12 is a watershed. At this age, they have to face the pressure of the junior high school entrance exam, and after entering junior high school, they will face the pressure of adapting to a new environment, dealing with new interpersonal relationships, and academic pressure is also greater, if they can't cope with these pressures well, they may have psychological problems. In addition, physiologically speaking, the age of 12 is also the beginning of puberty, a period of drastic changes in hormone levels in the body, they are becoming more and more like adults in appearance, but the psychological maturity is not enough to cope with the problems of life.
Parent: "How can a child get sick?"
Zhang Ye's head was shaking slightly, she could feel it, but she couldn't control it.
After her daughter Zhao Yue fell ill, she was under a lot of pressure. At the end of last year, she felt that something was not quite right and wanted to cry all the time, and the doctor said she was depressed and anxious.
In March this year, Zhao Yue was hospitalized for the third time in nearly a year. Her first hospitalization was just after her 14th birthday. At the age of 36, Zhang Ye became a mother, she believes that she has been more spoiled by her children since she was a child, and her expectations are also very high, but she is not overly "chicken baby" like some urban parents.
"I don't think there's a lot of time to accompany my children, and my dad and I have always been as dedicated to her as possible. Before the child's illness, I never felt that I had neglected her feelings, and I had never treated her badly materially and spiritually. Zhang Ye said, but after her daughter fell ill, she felt that it had become a "appearance".
Zhao Yue studied very well, and when he was in junior high school, he was admitted to a local key middle school, but the change also followed. Zhang Ye recalled that Xiaoyue's self-awareness gradually increased at that time, but she and her lover did not pay attention to the changes in the child in time, and there were still more "controls" and "constraints" on her. "Mainly in electronic products, the way is not quite right, it is more crude. ”
During the summer vacation, Zhao Yue's mood began to be significantly depressed, she didn't want to contact her classmates, she didn't want to study, and she had self-hurting behavior. Zhang Ye felt that it was not right, so he took the child to see a psychiatrist.
At a psychological counseling center designated by a local psychiatric hospital, the counselor said that Zhao Yue was just a general adolescent problem and that there was no major problem. She felt that since it was an adolescent problem, she would adjust it slowly, so she asked her daughter to do psychological counseling first, but found that it was useless. Later, Zhao Yue said that it was impossible for her to open up to a stranger.
When she was in the second grade of junior high school, Zhao Yue began to become irritable, her interest in learning declined, her concentration and memory deteriorated severely, she suffered from insomnia, and she reversed day and night.
"Looking back, she was sick at that time. Zhang Ye said that in March last year, Zhao Yue was preliminarily diagnosed with "depression, anxiety, and bipolar disorder" at Anding Hospital and needed to be hospitalized. However, at that time, she and her daughter were very anxious and disgusted with hospitalization, and they were discharged after a month and a half. She admitted that from the current point of view, Zhao Yue did not have the conditions to be discharged from the hospital at that time.
In the courtyard of the pediatric ward of Anding Hospital, this is a place for children to play and play (photo provided by the interviewee)
Chen Xu and Zhang Ye, chief physicians of the Department of Child Psychiatry of Anding Hospital, are already old acquaintances. She recalled that at that time, Zhang Ye, like many parents, had many misunderstandings about the disease itself and the child's condition, and quarreled with the doctor a lot.
Zhang Ye said frankly that at first, she and her lover couldn't accept it, "How can a child get sick?"
They once blamed themselves, feeling that they had done a lot of wrong things in the process of their children's growth, and even felt that they had ruined their children. "When you see another child going to school happy, no matter how well he studies, at least he is healthy. But when I see my own children, I always feel that I have suffered too many sins, both physically and mentally. ”
"Parents should learn to accept their children, only when they accept their children and change themselves first, their children will change, not just to see their children, and simply let them change. She said.
It is not easy for parents to move from "accepting their children" to "changing themselves". Wang Gang, president of Anding Hospital and director of the depression treatment center, mentioned in an interview with the media that some parents have a strange mentality, as if the disease does not occur, but is "dispensed" by the doctor, as long as they do not see a doctor, they can be regarded as no disease. Some parents come to him not to treat their children, but to declare that their children are not sick, so that they can tell their children that the experts say that you are not sick, you have to study hard, and don't think about it. The essence of this mentality is that parents fear that their children will be labelled if they are diagnosed with mental illness, and they feel the stigma attached to depression by society, which creates stigma.
"Now there is another problem, the stigma of parents is much worse than that of children. Qi Junhui found that there are two types of parents of children, one is aware of the seriousness of the child's problem and is willing to cooperate with the doctor's treatment. The other type is to "pull the hind legs", the parents come and say: "I don't know what's wrong, I think it's okay, it's just that there are too many mobile phones, and he wants .......to come" In short, try to find various explanations to prove that the child is not sick.
He Fan once treated a mother and daughter, a thirteen or fourteen-year-old girl, who was diagnosed with depression. Before being diagnosed, the girl had been delayed in other general hospitals for at least 2 years, and her somatization symptoms were so severe that she could not go to school, but her mother felt that she had been examined in various departments and there was no problem, so she kept forcing her to go to school.
After learning the diagnosis, the mother was completely unacceptable, and He Fan was surprised by the fierceness of her reaction. "It's not often that I've seen parents react so violently. He Fan said that seeing the child crying and telling her medical history, and seeing the mother's reaction, she felt very sorry for the child.
Later, she never saw the mother and daughter again.
Doctor: "Discharge from the hospital is often the beginning of treatment"
"Every month, more than a dozen children in the paediatric ward are taken in and discharged early by their parents when they are not ready to be discharged, and the doctors try to persuade each parent to continue treatment, but to no avail. Chen Xu said that there are not a few parents who stop their children's medication, change the dose, and do not discharge the hospital according to the doctor's instructions.
Qi Junhui has a lot of dealings with such parents. She remembered that there was a child who was an "old patient" in their department, but she had only seen this child once, and then it was her grandfather who came to prescribe medicine. She guessed that the old man should be a high-ranking intellectual, because each time he brought a lot of information to guide her on how to use medicine.
"As soon as I asked to see my child, he said that he was busy with school. He doesn't let you speak, only says his own judgment, and then makes you admit that his judgment is right. Qi Junhui said.
As a doctor, she needs to repeatedly emphasize to parents that psychiatric consultations are irreplaceable and that children must be brought in. He Fan said that all diseases in psychiatry are clinically diagnosed, which means that the accuracy of the diagnosis depends more on the experience and professionalism of doctors, among which psychiatric examinations, mainly through direct conversation with patients, are particularly important.
March 29 was an open day for parents in the pediatric ward of Anding Hospital. On that day, parents can visit their children and visit the wards, but the most important part is a symposium that the hospital hopes to improve communication with parents.
At the parents' symposium, Shi Daoming was sharing educational concepts with parents (Zhang Shengpo/photo from CCTV)
On this day, Chen Rui's mother came. She told an incident at the symposium that her daughter suddenly had an emotional breakdown because she didn't buy a concert ticket. After the lecture, she raised a puzzle that many parents have: how should parents get along with their children after their children are sick, and how can they adhere to the principles of education in front of their children?
Ms. Tian, a psychotherapist who was present, gave an example of a child who told her that since she fell ill, her family had met all her requirements unconditionally. "When they were satisfied, I was stunned, my request was obviously wrong, why did they agree, didn't they have their brains? I did something wrong, and they said I was right, they didn't have a basic view of right and wrong?" said the child, who actually knew why, because the family thought she was sick.
Through this case, Mr. Tian wants to tell parents that due to their age, children sometimes have the psychology of "benefiting from illness", which is also a test of parents' parenting wisdom. Parents should keep the basic bottom line under the principle of "life safety first, harm minimization".
Shi Daoming, an intermediate psychotherapist, was also the moderator of the symposium. He suggested that parents should maintain a basic judgment of right and wrong when dealing with their children. For example, what should be done and what should not be done, what can be bought, and after how much money is exceeded, you can't buy it.
"These bottom lines must be conveyed to the child, and on the premise of ensuring the safety of his life, the bottom line should be adhered to, and the whole family must agree on this bottom line, otherwise it will be invalid. Shi Daoming said that every parent may want a fixed answer, but in fact, no, because the situation of each family is different, and the child's condition is constantly changing, parents should achieve a dynamic balance like a seesaw in the interaction with their children.
Many doctors said that to some extent, mental disorders, including depressive disorders, are a chronic disease, just like diabetes and high blood pressure, and patients should improve their lifestyle and adjust their mentality in addition to long-term medication, so family care is crucial.
"Discharge from the hospital does not mean the end of treatment, it may just be the beginning. After the child is discharged from the hospital, a family still has a long way to go. This is a sentence that Shi Daoming often says to parents.
Chen Xu said that parents need to face up to the disease of depressive disorder, neither to take it lightly, nor to panic. It should not be underestimated, that is because more than 50% of mental illnesses are first manifested in adolescence, there is no need to panic, that is because in this period, often in the early stage of the occurrence of the disease, early identification and standardized intervention can prevent the occurrence and chronicity of the disease, as long as through adequate treatment, to ensure that the condition is stable, all children have great hope to return to a healthy state.
Expert: There are deficiencies and biases in parents' cognition
After graduating, Chen Xu has been working in pediatrics. Over the past decade, she has witnessed the change in the number of patients with pediatric mood disorders. She remembers that around 2007, the maximum number of pediatric outpatient visits per month was about 300, and the annual outpatient volume was less than 10,000, and 20 beds were enough.
"At that time, pediatric patients were polarized, and some of them were patients with neurodevelopmental disorders such as ADHD and Tourette's syndrome, which could be treated on an outpatient basis. The other group is severely ill, such as schizophrenia. Chen Xu introduced that in 2018, the annual outpatient volume of the pediatric department of Anding Hospital has reached 670,000 person-times, and the number of beds has increased from 20 to 57, which was full within a week. Since that year, the number of pediatric patients in Anding Hospital has begun to surge, and last year the number of outpatient visits reached 100,000, and the number of beds has also increased to 80.
"Although some of these patients have developmental problems, more than 50% of them are children with emotional problems, including depression, anxiety, bipolar disorder, childhood mood disorder and other diseases. She said.
Xu Tao, an adult psychiatrist at a district-level hospital in Beijing, went to the pediatric ward of Anding Hospital this year for further training. In recent years, more and more relatives and friends have come to him to consult on the psychological problems of children and adolescents, and he is limited by his professional knowledge, so he cannot answer many questions. However, more people asked, and he began to wonder, why are there more and more children with emotional problems?
A number of child psychiatrists said that in the medical community, the cause of depressive disorder has not yet been clarified, but it is certain that it is a mental illness that is highly related to biological, psychosocial and environmental factors. Biological factors are more related to genetic factors, which are not controllable by human beings, and theoretically do not become the main factor in the surge of depression among children and adolescents in a society.
Zheng Yi said that the biggest reason for the mental health problems of children and adolescents is family relationship problems. The World Health Organization has done a survey, family factors account for 70% of people's mental health, while biological factors and genetic factors only account for 15%~25%.
He Fan's feeling is that in recent years, in general, the number of diseases with high genetic factors has not increased significantly, but the number of diseases with high social psychology and family environment has increased significantly. "In recent years, there have been significantly more children with emotional problems, among which anxiety and depression are more prominent. ”
Some parents once told Zheng Yi that he panicked when he saw his child playing, because everyone else was learning.
Shi Daoming believes that the reason why some parents have such high requirements for their children is because they feel a lot of competitive pressure in society, and these pressures will naturally be passed on to their children.
In the pediatric ward of Anding Hospital, a girl's bed is filled with textbooks, toys, and extracurricular books (Zhang Shengpo/photo by CCTV)
"With the development of society, schools are becoming less and less tolerant of children. Not to mention the phenomenon of '10 minutes between classes is not free', frequent calls to parents, parent-teacher conferences, and the burden of schoolwork...... These will increase the child's stress, and the impact of stress on people is inverted U-shaped, appropriate pressure has a promoting effect on the child's psychological development, but too much pressure will have the opposite effect, this pressure can not be solved at their psychological age, it may lead to various emotional problems and behavioral problems. He Fan said.
According to the survey, the overall prevalence of mental disorders among children and adolescents is 17.5%, but in fact less than 20% of adolescents have received appropriate diagnosis and treatment.
"This is a big problem, why are so many children not being treated?" Zheng Yi said, the most important reason is that parents do not have enough understanding, and second, there is a misunderstanding, because there is still serious discrimination and stigma against mental illness in society.
He Fan's observation is that compared with children's mental health, many parents pay more attention to their children's functions, as long as they can go to school and study well, everything is fine. It is only when a child is unable to go to school that there is a real concern about the child's psychological problems. In fact, it has been a long time since a child has developed depressive symptoms to not being able to go to school, which is the main reason for the delay in early identification and diagnosis of children and adolescents.
Coordination between medical care and education is an important part of prevention and treatment
Zheng Yi has been working in this field for 40 years. He recalled that in the 80s and 90s of the last century, child psychiatrists were rarely taken seriously, and their income was not as good as that of many departments. Even within the medical system, there are many misconceptions about children's mental illness. He once heard a health care system leader say, "Do children still have mental illness?"
Chen Xu said that in recent years, with the increase in social demand for medical treatment, many provincial psychiatric hospitals have also begun to add pediatrics, increase beds, pediatric outpatient clinics and wards have sprung up like mushrooms after a rain, a provincial hospital in the north is built a pediatric ward with 400 beds, and a specialized hospital in a prefecture-level city in southwest China has 200 pediatric beds.
Zheng Yi said that some hospitals have opened child psychiatry departments, but there are no doctors, so many former child care doctors and adult psychiatrists have been transferred to child psychiatric departments to open outpatient clinics, and they may not have enough professional qualifications. Recently, while researching an autism treatment center, he found that two of his three children were misdiagnosed with autism.
According to a 2019 article in The Lancet Psychiatry by Professor Wu Jinlan's team from the Department of Pediatrics of the First Affiliated Hospital of the University of Science and Technology of China, there is a scarcity of child psychiatrists in China, with less than 500 child psychiatrists in the country, and the distribution is extremely uneven. Many doctors said that at that time, this estimate was only a lot more, but it is difficult to estimate the exact number now, mainly because China has not yet established an independent child psychiatrist practice system. Even like Zheng Yi and He Fan, their physician qualification certificates only say "psychiatrist".
"If you don't have standards, you can lead to chaos. Therefore, Zheng Yi has been calling for the establishment of a child psychiatrist certification system as soon as possible.
Qi Junhui is discussing the treatment plan with her colleagues (Zhang Shengpo/photo by CCTV)
In Zheng Yi's view, like many diseases, early screening and early treatment are the key to prevention and treatment, and children's mental illnesses are no exception. Among them, the coordination of medical education should be a very important part of the prevention and treatment process.
This can be reflected in the many policies and regulations formulated by the state over the years. For example, in 2019, 12 departments jointly issued the "Healthy China Action - Action Plan for Child and Adolescent Mental Health (2019-2022)", which proposes that by the end of 2022, a social environment conducive to the mental health of children and adolescents should be basically built, and schools, communities, families, media, In 2023, the Ministry of Education and 17 other departments jointly issued the "Special Action Plan for Comprehensively Strengthening and Improving Student Mental Health in the New Era (2023-2025)", which clearly stipulates that the administrative departments of education shall strengthen mental health education for minors and establish mechanisms for early detection and timely intervention of minors' psychological problems; in 2023, the Ministry of Education and 17 other departments jointly issued the "Special Action Plan for Comprehensively Strengthening and Improving Student Mental Health in the New Era (2023-2025)", which proposes that the work objectives are "health education, monitoring and early warning, The "four-in-one" student mental health work system of counseling services and intervention and handling has been improved, and the pattern of student mental health work coordinated by schools, families, society, and relevant departments has been improved.
Allowing hospitals, schools, families, and society to participate in the prevention and treatment of depression in children and adolescents has always been Zheng Yi's view. At an Asian Education Forum, he pointed out the necessity of improving the "mental health service system", so that school psychological service platforms, community psychological service platforms, mental health growth counseling centers for minors, socialized mental health service institutions, and children's specialized hospitals participate in and support together to build a strong security network.
"Actually, the hospital can play a very good role in threading the needle. Zheng Yi said.
Zheng Yi said frankly that in the past, psychiatrists were not very popular with schools, but in recent years, with the release of some national policies, the attitude of schools towards psychiatrists has changed, and some schools have even invited psychiatrists to be part-time vice principals, but now the problem is that the school's understanding of children's and adolescents' mental health problems is still too simplistic.
"The document was issued, and the school had to pay attention to it. However, some school leaders do not truly accept psychiatrists from their hearts, and they are often very respectful on the surface, but the discrimination and fear of mental illness itself are still deep-rooted, and there is no specific willingness and method of in-depth cooperation. He said.
A child psychiatrist said that from a public health perspective, they want to do a lot, but often the more they want to do, the more frustration they feel. "We want to do some early screening, screen out those high-risk children, and do early intervention, so as to reduce the occurrence and development of the disease, but the school is unwilling to cooperate with us, and the so-called linkage is completely unreasonable. From a policy point of view, great attention is paid to the mental health of children and adolescents, but there are many difficulties in the specific implementation level. For example, when multi-department collaboration, who listens to whom and who will co-ordinate?"
In his view, few school principals are willing to let doctors screen out what percentage of their students have depression and mental disorders, and they feel that knowing the data will not solve the problem. If there is any accident, you can also say that you don't know, if you screen out and there is an accident, the nature will be different.
"If it is really screened out, who will tell the parents? What should be done with the follow-up intervention? How can the child be said to be in a high-risk state and needs attention? Then the doctor must bear the final responsibility for the explanation. Since ancient times, there has been a tradition in the mainland of 'doctors do not knock on the door', so how can a doctor take the initiative to find someone and say, 'Your child is sick'!" the doctor said.
Zheng Yi said that medical and educational cooperation should be an overall cooperation, how to divide the responsibilities and powers of functional departments, how to mobilize the enthusiasm of doctors, and how to help children after problems are found in the early screening process, all of which should be guaranteed at the institutional level. "In this way, there can be a sustainable mechanism, instead of a small number of doctors who rely on personal relationships and personal interests to promote their work. Zheng Yi said.
(Li Ting, Chen Rui, Zhang Ye, Zhao Yue, and Xu Tao are pseudonyms in the article)
Edited by Fan Fan
Source: CCTV