«Parents should know more about child development»

Mr Bilke-Hentsch, which mental disorders do you see most frequently in children and adolescents?

These are anxiety disorders and various forms of depression, followed by ADHD and, at some distance, obsessive-compulsive, eating or trauma-related disorders. Girls are predominantly affected by internalised disorders such as depression or anxiety disorders, while boys are affected by externalised disorders such as ADHD or drug or gaming addiction.

And how many children and young people have a mental disorder?

International long-term studies have been carried out regularly for many years, and at any one time around 20 per cent of the participants showed mental health problems.

The pressure and demands of a competitive society do not leave children unscathed.

This means that if I were to examine 100 children on the street on any given day, around 20 of them would show a mental abnormality. That's quite a high percentage, but it's relatively constant. During the coronavirus pandemic, however, the percentage has risen to 30 per cent.

How many of those with mental health problems need treatment?

Around half, i.e. 10 out of 100 children - but only a tenth of these are treated. It is a major problem in paediatric and adolescent psychiatry that a significant proportion of those affected do not receive diagnosis and treatment at all. Even before coronavirus, demand was already rising sharply. We have been observing this since around 2010. 2017 saw another jump.

Why is that?

There are many different reasons for this situation. We are experiencing a fundamental crisis in the meritocracy, the pressure and demands of which have left their mark on children and young people. In addition, acute crises have become more frequent in the last two to three years: global warming, the measures taken during the coronavirus pandemic and the war situation, which does not affect us directly, but indirectly and emotionally.

In the past, separated children were just as well off or better off than those whose parents were still together - today they are worse off.

In this context, we speak of a so-called learned helplessness, which means that we repeatedly find ourselves in situations in which our individual and social abilities are not sufficient to cope with the situation. We experience ourselves as helpless.

The high divorce and separation rate also contributes to this development. Studies show that for the past ten years or so, children of divorce have been worse off than in previous generations.

What has changed in break-ups compared to the 80s or 90s?

At that time, separated children were on average doing just as well or even better than children whose parents were still together. By separating their parents, they got out of the chronic conflict situations. Today, couples separate much earlier and then argue about maintenance, child-rearing and so on. So the separation does not mark the end, but the beginning of the stressful situations for children.

Experts are divided as to whether there are actually more children and young people with mental health problems today or whether the diagnosis has simply become more differentiated. What do you think?

Of course, there are many more therapeutic options available today than there were 50 years ago, but child and adolescent psychiatry has not fundamentally changed in the last 20 years. The fact is that case numbers have been rising in many countries for many years and children are being referred to psychiatric services because they can no longer cope at school or at home.

Some would rather discover a disorder in their child than admit to themselves that they need to change their parenting behaviour.

On the one hand, the complexity of cases has certainly increased. Two, three or even four other disorders are added to an underlying illness and the psychiatrist has to decide which disorder to tackle first. On the other hand, we also receive cases that actually need something other than psychiatric treatment.

Tell us.

There are social classes who would rather discover a disorder in their children than admit to themselves that they need to change their parenting behaviour, for example by becoming more consistent, setting clearer rules and entering into conflicts with their child.

For these parents, it is simply easier to say, my child has ADHD or is autistic, so the problem is localised outside the family and can be explained socially or biologically.

Which parents are you talking about?

These are mainly mothers and fathers who, on the one hand, are very preoccupied with their own professional activities and like to have well-functioning, presentable children and, on the other hand, are reluctant to enter into serious conflicts with their children and defend their own values. They hope that the child will somehow develop well. But as a parent, I have to practise negotiating aggression and conflicts with my child at every age.

How do you deal with these cases?

For us therapists, parental intentions are of secondary importance. We primarily look at the child: what functional limitations does the child have? Does it fulfil the usual developmental tasks that all other children do? Is it coping with the usual stress and strain? And are they reasonably stable, in a good mood and creative? We use these and other indicators to determine whether treatment or educational counselling is appropriate.

What factors favour a mental disorder?

There is always a combination of factors. Genetics plays a very central role. However, it is not the mental disorder as such that is inherited, but the likelihood of developing it. Then social factors play a role, which lead to this predisposition breaking through in the first place, known as epigenetics.

What are they?

There are many, such as long-term neglect, violence in the family, poverty or individual traumas such as accidents or parental divorce. Healthy children can usually cope quite well with two to three risk factors. From a number of four to six, the mental illness is very likely to break out.

Our inpatients have eight to nine risk factors and our outpatients have two to six. These factors exist side by side, reinforce each other and must be tackled individually or in combination. The trick is to find out which risk factors can be reduced together and which the patient must learn to tolerate.

Suicides are also on the increase.

That is partly true. The number of cases has been rising steadily for around ten years and has increased significantly since the coronavirus pandemic. However, we have to differentiate between completed suicide, which leads to the death of the young person, and suicide attempts. We are seeing a significant increase in the latter in particular. These are usually impulsive reactions to a psychologically stressful situation.

When suicide is a constant topic in a young person's online filter bubble, they get caught up in a kind of maelstrom.

We also observe a tendency to regularly consider suicide as one of several possible solutions. «Suicidal ideation» is the technical term used when the young person concerned thinks about suicide over and over again. And if she is then stuck in a filter bubble on the internet where suicide is a constant topic, she gets caught up in a kind of maelstrom.

This is one of the main problems of our patients: they spend a lot of time coping with their thoughts and feelings and use up mental energy that they could actually be using for other things - for studying or partying, for example. Whereas healthy adolescents are usually able to put these negative thoughts, which they naturally also have, to one side.

It is often very difficult for parents to distinguish the onset of a mental disorder from normal pubertal behaviour.

Parents are known to be relatively unsuited to recognising depressive and anxious symptoms in their own children. They are simply too close. Teachers, trainers or other people who meet many children in their everyday lives are much better at sensing and noticing that changes are taking place in a child.

Why is that?

These people are compared to their peers. If the whole class reacts in a certain way and only one pupil does not, this is conspicuous. Teachers and trainers also see children constantly in a performance situation in which they can measure whether a child is receptive and capable or not. And they have already seen an immense number of children and young people and can observe the changes that take place over the years.

Burnouts usually affect particularly hard-working, intelligent girls who have high expectations of themselves.

Of course, the children themselves also play a role here. They often want to go easy on their parents, who are already faced with many demands. They easily feel guilty. The 12-year-old depressive girl, for example, initially withdraws into her thoughts. If puberty is added to this, it becomes even less likely that the child will confide in their parents.

But what can parents do then?

Parents should simply acquire knowledge about child and adolescent development, i.e. development during the teenage years. This can be found in books on developmental psychology, which are available in every bookshop. This knowledge then complements parental intuition.

It's reassuring to know, for example, that many 13-year-olds leave sports or music clubs and prefer to hang out with their mates, while 7 to 9-year-olds can still be motivated to take part in many activities. So for the time being, there's nothing to worry about.

In a second step, I would ask myself the question: In what areas does my child deviate from the average developmental level of their peers? And how much? And only then consider whether there could be pathological behaviour somewhere. There are experts who call for more serenity in parenting. That is very helpful, but I can be even more relaxed on the basis of basic knowledge.

One book that has caused quite a stir in recent years is «Burnout-Kids» by German child and adolescent psychiatrist Michael Schulte-Markwort.

Burnout usually hides a depression of exhaustion, which in children and adolescents results from excessive demands in school and leisure activities. The issue usually affects particularly hard-working, intelligent girls who place high demands on themselves and can be traced back to social developments in recent decades.

In urban environments in particular, we observe high demands in leisure time as well as at school.

Particularly problematic in these cases are parents who exemplify a very pronounced performance mindset, but send other messages to the child verbally. «We don't care what you do later in life, the main thing is that you'll be happy.» The child is then easily caught in a so-called «double bind situation». On the one hand, it has the daily parental role model and on the other hand, the parents say something completely different to what they exemplify.

What advice do you have for parents?

To think carefully: Where am I really living something? And where am I just talking about it? Honesty is exhausting here, but necessary. In the urban environment in particular, we observe high demands in the leisure sector in addition to those directly related to school: piano, tennis, ballet, creative courses - the list is long.

The problem is that this tightly scheduled daily routine means that there is hardly any unplanned family time left. But this would be important so that the children have space and time to simply express their thoughts.

Another piece of advice to parents would be to give children this time and ask them without obligation how things are going with their best friend or how the new teacher is getting on in class, but not in a confrontational way, but in a relaxed and casual manner. Even a short story from your own childhood can be a door opener if it is not told at epic length.

Let's say your 10-year-old son comes home with a report card that is worse than the last one. How should I deal with this as a mum or dad?

Well, there is that. In such a case, I would first ask myself: What subjects are involved? What is the content? What are the subjects and has he learnt the requirements and prepared himself well? Where do I need to take a closer look and practise with my child?

Doesn't this report card simply reflect the reality that the school material is becoming more difficult? And then I would be quietly pleased if the child reacted to poor grades with a certain amount of anger and frustration and drew motivation from it, along the lines of: I'll show the stupid teacher!

And if it doesn't?

Then I would have to guide the child in this respect and look at where their own part in this grade is and what they need to do to compensate for it. Otherwise, I'll make up a fantasy world for the child and at some point reality will emerge.

What do you mean?

Let me explain it using an example: There is a group of 15 ski students who all receive a gold medal after the final race. None of them are at the top of the podium, they are all winners. But the next day, a ski group is formed to compete against the neighbouring camp and three of the 15 are selected. The remaining 12 ask themselves: "I won the gold medal yesterday and today I'm nothing?

In my view, it is a very strange, presumably unconscious counter-reaction by some adults to symbolically disguise our meritocracy in some areas. In the reality of children, however, it is fully realised. That's what I mean by this discrepancy between acting and speaking.

You once said in an interview that you mainly treat girls from their teenage years onwards. Where are the boys?

We don't know exactly. But let me first differentiate. In Lucerne, we see around 1,200 children and adolescents per year in the outpatient sector and around 300 in the inpatient sector. The latter are seriously ill and often at acute risk of suicide. And in this area, we have definitely been seeing more girls than boys for about two and a half years, a ratio of 9:1. That worries us. But perhaps the boys are managing to cope better with the uncertainties of recent years, which would be good news.

What could be the reason for this?

Boys - and men - tend to have the ability to block out problems, suppress them and simply turn their attention to other things. Not every boy, of course - I'm talking about the average. For example, we know that boys generally cope better than girls in separation and divorce situations.

Social networks have a particularly negative impact on girls and women who are prone to depression.

Boys also don't need as many successful relationships - and these aren't constantly scrutinised like they are for girls. «Are you still my best friend?» - boys usually don't even ask themselves this question, it's a settled issue. What's more, boys today are able to organise success in precisely those areas through highly personal computer games that they don't have in real life.

While girls spend most of their time on social networks.

And these «comparison portals» have a particularly negative effect on girls and women who are prone to depression. At some point you internalise it: I'm not worth anything anyway. And then even parental reassurances no longer help. The algorithms are programmed in such a way that derogatory, critical and negative things are shown a little longer than positive things, as these things get more attention.

For example, in the case of self-harm: «We can't see anything», a girl is told when she shows her scratched arm. So the girl enlarges the picture. «But that's not what we meant, make the injury bigger!» The girl hesitates, but sees that seven of the 18 people watching have already switched off. So she makes the injury bigger. Suddenly there are 23, then a teenager appears with an even bigger injury and the girl is out. But the tissue damage is there and the lasting psychological damage is often underestimated.

For some time now, more attention has been paid to the topic of mental health and numerous campaigns have been launched.

This is definitely the case at city and cantonal level. More needs to happen at federal level. Where school authorities and the healthcare system work together constructively and have a shared interest in mentally healthy pupils, apprentices and, ideally, students, things are much better.

This is a crucial interface. School social workers are of the utmost importance, and a school psychology service must also be equipped accordingly. We discussed this at the beginning: Calm and well-trained professionals who deal with children and young people on a regular basis are the most important people when it comes to detecting emotional distress and helping families at an early stage.