3 High risk and vulnerable people

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Contents

• Objectives
• Introduction to high risk and vulnerable people
• Maternal mental health
• Infant mental health
• Adolescent mental health
• Mental health in the elderly
• Care workers
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Understand common mental health conditions in pregnant women and new mothers.
2. Understand infant mental health.
3. Understand adolescent brain development and why this is important.
4. Understand why adolescents are at high risk for mental health conditions.
5. Know the relationship between pregnancy in adolescents and risk for mental health conditions.

Introduction to high risk and vulnerable people

3-1 Can anyone develop a mental health condition?

Yes. Anyone can develop a mental health condition. However, some groups of people have a higher risk of developing mental health conditions.

3-2 Which groups of people have a higher risk of mental health conditions?

There are some groups of people who are more vulnerable and have a higher risk of a mental health conditions. These are:

• Pregnant women and new mothers
• Babies (infants)
• Young children
• Adolescents
• The elderly
• Care providers.

Maternal mental health

3-3 Why do mental health conditions occur during pregnancy and after childbirth?

Change is stressful. During pregnancy and after childbirth, women go through many emotional and physical changes as they become mothers. They can also experience many new challenges at work and in their relationships. Some mothers find these changes even more stressful if:

• They are living in poverty, especially if they are hungry and afraid
• Have been exposed to neglect, violence and abuse
• Are living with HIV
• Their pregnancy was unplanned or is unwanted
• They are very young (adolescent)
• This is their first pregnancy
• They are experiencing stigma or rejection or feel alone.

These mothers all have a much higher risk of common mental health conditions.

3-4 What common mental health conditions affect mothers?

Mothers can develop the same mental health conditions as anyone else. In South Africa, 1 in 3 pregnant women will have depression or anxiety. These mental health conditions are more common during pregnancy and up to a year after the baby is born. It is important to notice mental health conditions as early as possible so they can be treated before they cause more problems for the mother and the baby.

Mental health conditions, especially depression and anxiety, are more common during pregnancy and after childbirth.

3-5 Is the ‘baby blues’ a mental health condition?

It is normal for mothers to feel worried or sad after their baby is born. Some people call this the ‘baby blues’. It starts about three days after delivery and lasts for a week or two. Baby blues make the mother have sudden mood swings (feeling very happy, then very sad) with crying for no reason, feeling impatient, irritable, restless, anxious and lonely. Mothers can usually be helped to feel better at this time with kindness, care and support.

If the baby blues last for longer than two weeks, or they get so bad that the mother struggles to look after herself or the baby, then she may have developed a mental health condition.

Mothers with ‘baby blues’ feel worried or sad during the first two weeks after delivery.

3-6 What is postnatal psychosis?

Postnatal psychosis is a rare but serious mental condition that can start suddenly after the baby is born. The mother loses touch with reality and can start to think someone is trying to harm her or that her baby is evil. These mothers can become very angry or may look very afraid and hear voices that are not there. Other mothers may be very still and quiet, or overactive and energetic. This is a serious illness and must be treated quickly by doctors. If you think a mother has postnatal psychosis, she should not be left alone and must be sent to hospital at once as there is a risk the mother may harm herself or her baby.

Postnatal psychosis is a serious mental health condition when the mother loses touch with reality after delivery and may harm herself or her baby.

3-7 How do common mental health conditions affect mothers?

The signs of depression and anxiety are the same for mothers as for other people who suffer from these common mental health conditions. Anxiety and depression will change how she feels, thinks and behaves, and this can make life very difficult because:

• She may be unable to look after herself, her home, family or work
• She may struggle to connect with or talk to other people
• She may struggle to bond with, breastfeed and care for her baby
• She may have many arguments with family and friends
• She may not want to see anyone at all.

3-8 If a mother has a common mental health condition, how does this affect the infant?

Anxiety and depression in a mother during pregnancy and after childbirth can cause many problems for the whole family, but especially the baby. Severe anxiety during pregnancy can cause the unborn baby to be born small or too early, and these mothers often have problems after delivery. Anxious mothers often have difficult births.

Depression in the mother and/or father can cause babies and young children to be neglected and physically or emotionally abused. These children may later do badly at school and can develop mental health conditions themselves.

Mental health conditions in the mother may affect the unborn and newborn baby.

3-9 Why is it important to notice mental health conditions early?

It is important to notice mental health conditions in pregnant women and new mothers as early as possible so they can be treated. If mental health conditions are not treated, they can get worse and cause:

• More chance of suicide
• Bigger risk of substance or alcohol abuse
• Bigger risk for harm to the baby
• Babies that don’t thrive (do not grow well)
• Poor development of the baby’s brain
• Poor bonding and breastfeeding problems
• Behaviour problems in the older child
• Mental health conditions in the child, which can continue into adolescence and adulthood.

3-10 Why are maternal mental health conditions more common in pregnant adolescents?

Adolescents have double the risk of depression and anxiety. This is because adolescent mothers often:

• Feel very afraid about the birth and how they will manage
• May feel lonely and miss their friends if they drop out of school
• Feel judged, stigmatised and rejected because of the pregnancy
• Are usually not supported by the father, who may either be chased away or choose to leave
• May feel they have no future.

Adolescent mothers have a higher risk of mental health conditions.

Infant mental health

3-11 What does the word infant mean?

Infant means a very young child. In this book, we use the word infant to include newborn babies and children up to the age of around 3 years.

3-12 What is infant mental health?

Infant mental health is a positive state of wellbeing in which the baby feels safe and able to trust the world around them. This allows babies to:

• Make close and secure relationships with the mother and others
• Learn from and explore their world
• Experience, show and manage their emotions
• Build ways of thinking and using information.

3-13 Why is infant mental health important?

The baby’s brain grows and develops more in the first 3 years than at any other stage of life. This brain growth starts before the baby is born. By the age of 3, the baby’s brain is 80% of the adult size. A safe and caring home is important for the brain to grow and develop normally. The first 1000 days from the start of pregnancy to 2 years of age is the most important time for brain development.

The first 1000 days from the start of pregnancy to 2 years of age is the most important time for brain development.

3-14 What do infants need so they can develop healthy minds?

There are quite a few things that infants need for mental health. These are:

• A warm, responsive and secure relationship with the main carer
• Loving, kind, interested and caring experiences with others
• A stable routine and familiar adult
• Feeling safe with as little stress as possible
• Adequate physical care, food and sleep
• Stimulation through talking and play.

Babies who have a positive early start to life are able to use this as a base for success in later life, and are more likely to succeed in relationships at school, work and in the community.

3-15 Why is fear bad for infants?

Babies are helpless and need someone to care for them so they can survive. When their needs are not met, they quickly become frightened. Babies who have been exposed to toxic stress before birth or soon after birth are even more fearful. Feelings, like being alone, hungry, thirsty, cold, wet, tired or hearing cross voices, can make infants feel very frightened.

Babies cry when they need attention. They need an adult to show they care by coming quickly when they cry and by not being angry or rough with them. Babies need love and kindness. When babies feel attached and safe they can relax, grow and develop normally.

Babies need love and kindness to grow and develop normally.

3-16 Why is feeling safe and cared for so important to infants?

Babies who feel safe can develop trust. Babies who trust feel relaxed and positive. They feel confident and can get along with other people. Later in life these babies will grow up to be adolescents, and later still, adults who can manage their emotions, have more resilience, can learn, plan, problem solve and learn from their mistakes.

3-17 When do infants get emotions?

Babies develop emotions very early in life. They can feel sadness, anger, fear, love and pain. Babies don’t have the words to say how they feel, so they show emotions through crying, cooing, gurgling and smiling. Babies start to communicate with facial expressions and body language. The mother or caring adult needs to help babies manage and understand their emotions so they become less frightening.

3-18 What could happen to the infant if the mother has a mental health condition?

Mothers with a mental health condition can find it very difficult to talk to and care for their baby, and this can cause stress for the baby. It is important not to blame the mother. A supportive father or another adult will be able to help the mother and make sure the baby gets the positive start it needs.

3-19 What are the signs of poor mental health in infants?

You may notice that the baby is withdrawn, which they show by turning away or closing their eyes. The baby may also not be thriving, and could either not put on weight or may even lose weight. Other signs are not making eye contact, smiling late, being very quiet or crying a lot.

Being withdrawn, not making eye contact and failing to thrive are signs of poor mental health in infants.

Adolescent mental health

3-20 What do the words ‘adolescent’ and ‘adult’ mean?

Adolescence starts at puberty when sex hormones make many changes happen in the child’s body and brain. It ends in early adulthood when the brain is fully developed. We use the words adolescent and adolescence in this book to talk about young girls and boys between about 10 and 24 years of age.

An adult is a person who is fully grown and developed. We use the word adult to talk about the older person who is responsible for the adolescent’s wellbeing. The adult is the person who makes sure the adolescent is cared for and protected physically and emotionally. This could be the mother, father, grandparents, other family members, foster parents, a teacher or care worker.

The body changes that happen during adolescence are described in the Child and Adolescent Care for Community Health Workers book of the Bettercare series.

3-21 What big changes happen in the brain of adolescents?

Adolescence is a very important stage of development when the child changes into an adult. It is easy to see the body changes, but we often forget about the big brain changes that happen at the same time:

• At puberty, sex hormones make adolescents very emotional. Their emotions can be very strong and can change very quickly.
• The reward centre in the brain is very active in adolescents, which makes them respond strongly to being admired and liked (rewarded), more than at any other life stage. This helps them to connect with others, but also increases the risk of peer pressure and also addiction.
• Habitual pathways in the brain get stronger and thinking is faster than before. But the part of the brain that helps make sensible choices is not properly developed. This means adolescents can be very impulsive. They take big risks and can do very stupid things.

3-22 Why do adolescents have a bigger chance of having problems with mental health?

Adolescence is a time of big change to both their brains and bodies. These changes can be frightening and very stressful if the adolescent feels unsupported:

• Puberty is frightening if adolescents do not understand why their feelings, behaviour and bodies are changing so quickly.
• This is the life stage where children move away emotionally from their parents and start to connect with people outside their home. Friends become very important to them.
• Adolescents will often ‘show off’ and try to impress others as they try to fit in and make friends.
• Adolescents fear failure and are easily shamed. They are deeply affected by rejection, stigma and bullying.
• Body changes can make adolescents very aware of how they look. They are easily embarrassed and will often compare themselves to others.
• The sex organs are growing and developing. This makes adolescents think about sex a lot. However, they are not yet physically or emotionally ready for sex.
• Adolescents can be very confused by their strong emotions and sexual thoughts, and may worry about their sexuality, especially if they don’t have someone they trust to talk to.
• Social media, television and advertising can be harmful because some adolescents develop unrealistic ideas and expectations about life. This can make them feel like a failure.
• Alcohol and other substances can change the way the brain grows and develops, and this will also change the way the adolescent thinks and behaves.
• The adolescent brain more easily becomes addicted to alcohol, cigarettes and other substances.
• Adolescents are half child and half adult. They need adult support and encouragement, while they also need to be allowed to explore their world and make decisions for themselves.

Half of all mental health conditions start by 14 years of age, and 75% before 18 years. This is because the most important time for brain and mind growth and development is in babies and from puberty until late adolescence.

Many mental health conditions start during adolescence, as this is a time of many brain changes.

3-23 How can adults help prevent mental health conditions in adolescents?

Adults play an important role in preventing mental health conditions from developing in adolescents. They can do this by understanding that this is a very difficult time. Adolescents who have supportive relationships with adults they trust and can talk to are more likely to thrive:

• Adults need to remain calm, be steady, set limits and help adolescents to develop positive ways of thinking.
• Adolescents need to know that adults will still care and keep them safe, even when they behave badly.
• Adults need to help adolescents take care of their physical body by making sure they get enough sleep, eat healthy food and exercise outdoors. This will help them to act positively. Studies show that diet and sleep are important risk factors for mental health condition in adolescents.
• Adolescents should be encouraged to develop friendships with others their own age. This can be done by playing team sports and joining after-school clubs.
• Adolescents should be encouraged to explore and take safe risks by trying new activities and doing new things like volunteering or visiting new and interesting places.
• Those who look after adolescents must take care of their own physical and emotional health, because adolescents can be very challenging at times.

3-24 What are the common mental health conditions that adolescents develop?

The mental conditions that adolescents develop most frequently are depression, anxiety, eating disorders, and alcohol and substance abuse. These conditions are the same as in any other age group. They may be more difficult to notice in adolescents because this is already a time of big change.

Common mental health conditions in adolescents are depression, anxiety, eating disorders and alcohol or substance abuse.

Depression and anxiety are described in detail in chapter 2.

3-25 Why do adolescents abuse alcohol and other harmful substances?

Adolescents like to take risks, experiment and try to impress their friends. This is normal. They can also use alcohol and other harmful substances because they make them feel good or powerful, or can help them escape from their bad feelings. This may lead to alcohol and substance abuse. Cannabis (dagga) is often abused.

3-26 Are harmful substances worse for adolescents than at other times of life?

Yes. Adolescents are at higher risk for addiction. This is because their brain is still growing, so it is more sensitive to harmful substances. There is also a link between early or long-term cannabis use and developing psychosis and schizophrenia.

Adolescents who abuse alcohol or other harmful substances are more likely to have problems at school and depression, to practice risky sexual behaviour and to commit suicide.

Adults should help adolescents avoid harmful substances.

Mental health in the elderly

3-27 Why do the elderly have a higher risk of poor mental health?

Mental health conditions such as anxiety and depression are more common in the elderly because:

• They face many changes
• They often live alone
• Poverty and poor nutrition are common
• They are often emotionally and physically abused
• Hearing and eyesight are often poor
• Dementia (worsening mental ability) is common
• They often have physical health problems such as high blood pressure and diabetes.

The elderly have a higher risk of poor mental health.

3-28 What can be done to promote mental health in the elderly?

Many simple things can improve mental health:

• Help older people to stay connected with family, friends and neighbours
• Allow them to talk about their problems and fears
• Encourage them to keep physically active and have a good diet.

Care workers

3-29 What is meant by care worker?

Care workers are all those people who work in areas where they are exposed to the suffering of others. They may be professional people like nurses, doctors and social workers. They may be less skilled, but work more closely with those who suffer, like community health workers. Other people, such as policemen, security staff and schoolteachers, may also be at risk, even though they do not always deal directly with problems.

3-30 Why are care workers a high risk group?

People who take care of other people can be stressed and very vulnerable to mental health problems if they do not know how to recognise and manage their own emotions. Care workers often put the needs of other people ahead of their own physical and emotional needs, but they also need to take care of themselves. If they don’t, this can affect their mental health, and their ability to give care to others.

3-31 What mental health conditions do care workers experience?

Care workers develop the same mental health conditions as anyone else in the community. This can be an even bigger problem if they live in the same community as those they look after. In these cases, they experience the problem as others do, but they also sometimes take on an extra burden from those for whom they care. Care workers who develop mental health conditions may end up causing harm instead of helping those they need to support.

Care workers need to give themselves the same care as they give to others.

Bettercare has a book called Empathetic Care dedicated to this topic.

Care workers should be supported as they face many emotional stresses.

Case study 1

Thabo is 3 months old. His mother, Nomvula, is a 16-year-old who dropped out of school when she became pregnant. Thabo’s father has a new girlfriend. Thabo is well dressed and looks clean, but he is not gaining weight. When someone says this to Nomvula, she starts to cry, and says she wishes Thabo had never been born. She says she wants to stop breastfeeding and put him on the bottle.

1. Is there anything in this story that warns you that this mother may have a mental health condition?

Yes, the mother is adolescent and has a young baby. She has a very high risk of a mental health condition. She has dropped out of school, and will have lost many of her friends. Her boyfriend has left her.

The baby, Thabo, is also at high risk. He is not gaining weight and his mother seems to be struggling with breastfeeding and wants to change him to the bottle.

2. Should you shout at Nomvula and tell her to grow up?

No! This adolescent must be struggling with all the responsibility of being a mother and also having to cope with feelings of loneliness and rejection. This does not mean that we must not worry about Thabo’s weight, but the best way to help him is to help his mother.

Case study 2

You have worked with Maluke for a few years. When she started in your team, she was always so kind and patient with even the most difficult people. Recently you have heard her shouting at children in the after-school programme. This morning you saw her hitting one of the young boys in the group, who she said was being cheeky.

1. What do you think about the way Maluke is behaving?

This is not appropriate behaviour. Adults must learn to manage their emotions and never hurt people. It is also against the law for an adult to hit a child. This does not mean that adolescents can do and say what they want to, or that adults should never do anything to stop this behaviour.

2. How will you know if Maluke has a mental health condition?

We can never see if someone has a mental health condition just by looking. Maluke is a care worker, so she is in a high risk group. We can ask Maluke the three Whooley questions as part of a kind and caring conversation:

1. In the past two weeks, have you been troubled by feeling down, depressed or hopeless?
2. In the past two weeks, have you had little interest in doing things?
3. In the past two weeks, have you been unable to stop worrying or thinking too much?

If Maluke answers yes to any of these questions, we should ask if she would like help with these feelings.

It is never okay for a care worker to hurt someone in their care, in the same way as it is never okay for an adult to hurt a child. Adults must learn to take responsibility for their own emotions and learn to manage these. It is important not to judge or blame Maluke, but she does need to find help or she should not work with vulnerable people.