Unhappy children in "happy" families

World Mental Health Day it was celebrated on October 10. In Serbia, it went relatively unnoticed, although the results of the "Study on the Prevalence of Psychiatric Disorders children and adolescents in Serbia" of the Institute for Metal Health (IMZ), in cooperation with the Faculty of Medicine and the Faculty of Philosophy of the University of Belgrade, say that one in five young people in Serbia - average age 14,7 years - meets the criteria for at least one psychiatric disorder. Specifically - to suffer from major depressive disorder, have suicidal thoughts, anxiety, anorexia or behavior disorder, and one in seven children also self-harm. What does this say about the society in Serbia for Aleksandra Savić Parojčić, coordinator at the Center for Mental Health of Children and Youth (CEZAM) and neuropsychologist at the Institute for Mental Health in Belgrade, comments on "Vreme".

"WEATHER" If the results of the IMZ research, according to which 20,4 percent of students in Serbia meet the diagnostic criteria for at least one psychiatric disorder, compare with WHO and UNICEF data published in 2024. and show that 14 percent of children globally meet the same criteria, can it be concluded that these findings indicate the need for the introduction of a national strategy for the prevention of mental disorders in children and adolescents?

ALEKSANDRA SAVIC PAROJČIĆ: The results of our research unequivocally show the need for an immediate response. If we talk about strategy, Serbia has a strategic document on mental health protection. It was adopted by the Ministry of Health for the period from 2019 to 2026, so we can rather talk about what has been done and what has not been done in five years.

In the first place, it was important to improve the normative and institutional response. This means modernizing the existing Law on Psychological Activity and the Law on the Protection of Persons with Mental Disorders, and then passing a law that has never existed in Serbia, namely the Law on Psychotherapy, which regulates who is allowed to engage in this very delicate work. All this has been pending for the sixth year. One of the unfinished business is the status of psychologists in healthcare, who, you will not believe, are not recognized as healthcare workers even though they receive specialization after three years of post-graduate studies at the Faculty of Medicine. Our colleagues in the region have achieved this a long time ago, look at Croatia, where there is also a Chamber of Psychologists.

How many psychologists and psychiatrists are available to citizens of Serbia??

This is another matter that was included in the aforementioned strategy, and on which, I can say, nothing has been done so far. According to WHO data from 2017, which unfortunately have not changed significantly, there are between five or six psychiatrists and four or five psychologists per 100.000 people in Serbia. And, according to the data of the Institute for Public Health "Batut" from the year 2022, we have a total of 123 employed psychologists in primary health care at the level of the whole of Serbia. There are less than fifty child and adolescent psychiatrists.

The strategy also established the need for Serbia to have twenty centers, which should be rationally distributed territorially. When the strategy was adopted, there were five of them, and now there are six - two years ago, the Center for the Protection of Mental Health was opened in Pančevo. You will agree that the number is far from twenty. The centers should deal with community mental health promotion, prevention and early intervention.

Therefore, our problem is not the absence of strategies and programs because they clearly exist, nor are they deficient compared to international standards, but the problem is that their implementation is delayed. The analysis of the achievement of the goals within the mental health section related to children and youth for the first three years until 2022 showed that most of the goals were not achieved. We can look for the reasons, first of all, in the answer to the question of whether the goals were realistically set at all, then whether we have the necessary resources for their realization, but also in the answer to the question of whether there is an integration of everything that was done in terms of the existence or non-existence of a body that was supposed to monitor the implementation.

Each additional year of age increases the likelihood of developing the disorder by 17 percent. How to understand this information?? Can this trend be influenced and how??

The increase with age means that what we call early intervention is missing. This includes, first of all, recognizing that a child or adolescent has a problem and is experiencing mental pain. Psychological problems in children do not manifest themselves in the same way as in adults. A child who feels some form of psychological discomfort will rarely go to bed and grieve, nor will he say: "I'm depressed", as we adults do, often uncritically. The way in which a child will manifest emotional problems is a drop in school performance or an outburst in behavior at school, then through anger, rage, aggressive or auto-aggressive behavior.

There is a lack of recognition of early signs of psychological discomfort from parents - that is, in the family, and then in school and society. There are two possible reasons, one is insufficient information or, as we say, psychoeducation, which is why parents do not know what to pay attention to. The second is insufficient attention to one's own child, that is, to his psychological problems. A parent will ask a child who has come home from school about his grades, more often than about his experiences and feelings. With the growing up of a child who was not provided with help in a situation where the problem and difficulty were in the beginning, the problem deepens and escalates or appears in some other form that is characteristic of older age. So, for example, something that was manifested through hyperactivity may turn into a social pathology in the form of abuse of alcohol, substances, betting shops... This trend cannot but must be influenced, especially through preventive work in the field of mental health of children and young people. Although 50 percent of mental health disorders manifest themselves before the age of 18, and 75 percent before the age of 24, only 30 percent of young people receive timely intervention. Therefore, in order to improve the mental health of young people, it is necessary to make psychological services available.

The girls are, according to the findings, more likely to develop psychiatric disorders, suicidal behavior and self-harm. Although this is a global trend, do you think that there are specific factors in Serbia that additionally influence its expression?

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In the context of the fact that about twenty cases of femicide are recorded in Serbia every year, as if there is also an increase in reported cases of sexual abuse of girls, it is clear that gender is a very important determinant of psychological problems of girls. Boys are culturally restrained from showing their feelings, but at the same time encouraged to express them through the so-called "masculine" behavior, which in a certain way relieves internal tensions, which is not the case with girls. Girls are allowed to show feelings and cry, but failure to meet their needs for attention, affection and support manifests itself through overexertion, physical symptoms, moodiness, and environmental pressure often leads to eating disorders.

It is possible that girls suffer a little more from another type of pressure that comes from social networks, which is related to physical appearance. It is very difficult in the etiology of disorders in an individual to distinguish exactly how much is biological, and how much is psychological, that is, personality factors or social factors of society. These are three circles that partly overlap, but the fact is that girls more often resort to inflicting physical injuries on their bodies. A minor injury to the body, only by classification, should reduce the serious wound on the soul. The physical pain briefly interrupts the unbearable and confused thoughts, and the girls punish themselves out of guilt for not meeting the expectations of others that they introjected into themselves.

Children from divorced families are also more prone to developing psychiatric disorders, as well as children who show higher levels of emotional dysregulation in the family environment. Do you think this pattern is specific to Serbia and why?? How to act on these risk factors?

Parental divorce is one of the main sociodemographic correlates of the presence of psychiatric disorders in children and adolescents. The risk for mental disorders is twice as high if the parents have ever been separated. However, even in a family that is complete, a higher score of emotional dysregulation proved to be a risk factor for the development of mental disorders in the child. It refers to families where emotions are not properly regulated. Children whose parents have rapid and unpredictable mood swings, as well as heightened emotional reactions and problems calming themselves and the child during a stressful event, do not develop a sufficient sense of security either in themselves or in the world of adults. In other words, in seemingly "happy" families, we have unhappy children who grow up in conditions of inharmonious family relations, often witnessing scenes of intolerance and violence. Almost a third of children from our sample (27,7 percent) experienced physical abuse in the family, whether they themselves were victims or witnessed physical aggression.

Improving the mental health of young people requires empowering parents in their roles and improving parental competencies. The school can provide this type of support to parents by disseminating information about positive examples and by referring parents to consultations with school psychologists. Do you know that in Serbia there is one psychologist or pedagogue for every 600 students? If that one pedagogue or psychologist has to deal with the process of teaching and education, he certainly lacks time for preventive work with children and parents.

From the research we see that 27,7 percent of respondents experienced physical abuse in the family, and only 5,4 percent physical violence at school. Does this suggest that the prevention strategy should be more focused on family functioning and the involvement of social services in the design of preventive measures?? How much is, in your opinion, social service is currently successful in such interventions?

Unfortunately, we tend to see social services as something of a last resort, something that is usually threatened against parents or children. The obligation of psychiatric institutions is to, when a child verbalizes that there is physical punishment, submit the report to the Center for Social Work. Parents often perceive it as an excessive measure and their own punishment with the comment: "Well, I had no choice." We hope that the entire social climate will change in this sense and that physical punishment and violence will not be the default answer to the problem. But that requires radical changes in the whole society.

When we talk about social aspects from the point of view of risk for psychological difficulties in children and young people, one of the leading ones is certainly family poverty. Access to services is particularly limited for these families, given that they cannot afford anything outside the system framework. Lower socioeconomic status is also related to smaller communities in Serbia, where services at the primary level of health care are unavailable due to the fact that the services of health centers often do not include a psychiatrist, especially a child psychiatrist, and especially not a psychologist. Also, small environments do not offer the support of a psychologist or a child psychiatrist through private practice. Our school psychologists are there to somewhat compensate for the lack of services in the health system, but it is also important that they are empowered through training and seminars. As part of this project, the Institute conducted training for educational advisors, and in smaller towns it is conducting training for the second time through the Minimum Package of Services together with the UNICEF office.

Too, 30 percent of respondents claim that they do not feel accepted at school, while 33 percent state that they do not have close and honest relationships with their peers. How much does this kind of social alienation affect the mental health of children and adolescents?

Those are really big numbers. There is an even higher percentage of those students who have some relationships with their peers, but do not perceive those relationships as close, honest and fulfilling. This tells us about loneliness as a problem today. For this reason, young people often turn to virtual friendships found in the "Internet world". In this way, they solve their loneliness in a roundabout way and with the line of least resistance, but at the same time they isolate themselves from their peers, giving neither themselves nor them a chance to get closer.

Od 4,5 percent of respondents who stated that they attempted suicide, the average number of attempts is about two. How should this data be interpreted??

Multiple attempts by the same young person suggest that people who attempt suicide once have a significant risk of re-attempting and realizing it, which indicates the need for continuous treatment and monitoring of the condition. The fact that in the population of our children between the ages of 11 and 19 the percentage of suicide attempts was determined to be 4,5 percent is extremely worrying. The data you presented about an average of two attempts with these children means that there were more than two. All this speaks of great mental suffering, the way out of which can be seen in the end of life. Regardless of the cognitive limitations of this age and insufficient awareness that the end really means the end and that there is no turning back after such an act, we as a society can always wonder if a young person has lost trust in the world of adults so much that he did not even ask for help.

Can measures be taken to reduce the likelihood of a re-attempt?

At the Institute for Mental Health, we noticed that, during and immediately after the covid pandemic, the number of self-harm and suicide among children and young people increased. The limit was then moved to 12 years. We saw the reasons in fear, which was difficult to articulate, but also in the isolation of children from the social environment, the reduction of socializing and the reduction of social support received in the peer group.

What I mentioned as causes, only in the opposite direction, are measures that can reduce the likelihood of new attempts - reintegration into the school environment through activities, sports, various forms of community. Voluntary work is not culturally close to us. However, helping others in similar situations, vulnerable, marginalized, and even animals is healing for a young, especially wounded soul.

It is a very important finding that a large number of respondents with fulfilled criteria for the disorder were previously suggested to talk with a psychologist, psychotherapist or psychiatrist, as well as the finding that they significantly more often had previous experience of such conversations. In this regard, hope is also given by the fact that 75 percent of respondents have enough confidence to trust a school psychologist.

The good thing about children and adolescents of the new generation is that they are much more open to the psychological help of experts. The problem of stigma is less pronounced in relation to older generations. The CEZAM experience speaks of the population from 19 to 25 years old as our most frequent users. Our goal is to reach high school students, we are sure that there are many problems in that part of the population. You know, today it is important to adapt communication channels to young people, so in this sense we hired a young team for social networks.

Another important finding is that of those who sought help, 71,5 percent said that these conversations helped them feel better. However, whether all children have equal access to such support? Is there a need for better and greater institutional support at the local level?, but also at the national level? In what way it could be realized?

The answer is certainly positive. Yes, there is a need for more centers outside the health system where young people can come without a card, instructions, even without written parental consent for those over 15 years old. The idea is for such centers to take root in other major cities of Serbia. Thanks to the understanding of the importance of such work and the support of decision makers in the Republic of Serbia, the Youth Center will continue to work as an Office and as a model of good practice for opening centers in Serbia.

After the May tragedy, apart from Ribnikar and schools in Mali Orašje and Dubona, we also offered psychosocial support in Mladenovac, Smederevo, Lazarevac and Pančevo. Our experience is that, unfortunately, the response was small. This means that additional work on destigmatization is important in small communities, but the availability of such support models is also important, which does not take place in psychiatric departments of hospitals precisely because of the contribution to destigmatization of mental difficulties in society.

CEZAM – a justified idea of ​​existence

I can proudly say that in April 2024, a free psychosocial counseling center, namely the Center for Mental Health of Children and Youth, CEZAM, was opened as a project of the Institute for Mental Health and the Government of the RS. CEZAM is separate from the psychiatric institution and is primarily intended for non-institutional mental health care. For now, it has fully justified the idea of ​​its existence, more than 7000 services in a year and a half testify to the great response of children, parents and young people in Belgrade. In the last eight months, 752 young people came to talk with young psychologists.

At CEZAM, we offer numerous contents that contribute to the well-being and well-being of mental health. We promote volunteer work and gather young people around this idea. Our young volunteers go through a short training, after which they help organize events in the space, promote CEZAM and the idea of ​​the importance of preserving mental health, visit schools and colleges, various events and fairs. CEZAM also offers workshops such as "social game evenings", then watching films and talking with a young psychiatrist about the content of the film, as well as various other activities that encourage interaction with peers.

In addition, CEZAM organizes psycho-educational forums for parents. Topics range from child development, parenting, sexuality to mental health disorders. Today, parents are often in doubt about whether a certain behavior is "normal", what they can consider normal, and what goes out of the box. For example, our research showed that children spend an average of 3,7 hours a day on their phones. It used to be unacceptable, and today parents wonder if it is.

Methodology

The research was conducted during 2024 and 2025 in 17 cities in Serbia, from Subotica to Leskovac. Respondents in primary and secondary schools were included, in a total of 39 schools (43,8 percent of primary schools, 56,2 percent of secondary schools). The number of respondents included in the sample is 2342, the structure by gender – 47,5 percent male, 52,5 percent female. Average age 14,7 years. An analysis of the connection between mental disorders and disorders with various bio-psycho-social factors was also made, as well as a prediction of the direction in which the development of the disorder will go if nothing is done.

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