STRENGTHENING MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT SYSTEMS AND SERVICES. MALAYSIA COUNTRY REPORT 2022

Nisaa Wulan

Julie Hennegan

Murdoch Children’s Research Institute

George Patton

Monika Raniti

Monash University

Jane Fisher

Consultant Psychiatrists, Ministry of Health Malaysia

Salina Abdul Aziz

Nazariah Aiza Harun

Nor Rahidah Abdul Rahim

Mohd Affendi Hashim

Centre for Mental Health And Well-being, HELP University

Marc Archer

The research was overseen by the UNICEF East Asia and the Pacific Regional Office (Rachel Harvey)

and UNICEF Malaysia (Sarah Norton-Staal, Jessica Sercombe, Hyung Joon Kim and Sim Su Tein).

The authors wish to acknowledge the valuable contributions of the Regional Technical Advisory

Group and Malaysia Country Technical Advisory Group to the conceptual framework, methodology,

interpretation of findings and review of reports.

Regional TAG

Malaysia Country TAG

Janelle Babb (UNESCO)

Sarah Norton Staal

Roshni Basu (UNICEF)

Feisul Idzwan Mustapha

Francisco Benavides (UNICEF)

Noor Ani Ahmad

Michelle Dynes (UNICEF)

Nurashikin Ibrahim

Akihiro Fushimi (UNICEF)

Andrew Mohanraj

Zeinab Hijazi (UNICEF)

Amer Siddiq Amer Nordin

Jennifer Hall (WHO)

Aida Syarinaz Ahmad Adlan

Kunihiko Chris Hirabayashi (UNICEF)

Izzatul Shima Md Thahir

Jo Lucas (Oxford Policy Management UK)

Azmaini Isa

Natia Partskhaladze (GSSWA)

Nor Hisham Ismail

Cassie Redlich (WHO)

Mohd Pilus Abdullah

Hugh Salmon (GSSWA)

Alexius Cheang

Martin Vandendyck (WHO)

Susheela Balasundaram

Natia Partskhaladze (GSSWA)

Anita Abu Bakar

Christina Popivanova (UNICEF)

Atirah Haizir

Thanks are also extended to Helen Cahil, Khadijah Madihi, Melba Manapol, and Nicola Reavley for

feedback on the conceptual framework, and to Samitha De Alwis for contributing to the review of

policies and legislation.

We would like to thank the Director General of Health Malaysia for his permission to publish this article

2 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Executive summary

The mental health of children and adolescents aged 0-18 years is one of the most neglected health

issues globally. Before COVID-19, the World Health Organization (WHO) estimated that 10 to 20 per

cent of children and adolescents worldwide experienced poor mental health, with half of mental

disorders beginning by age 14.¹ In East Asia and the Pacific, almost 1 in 7 boys and 1 in 9 girls aged

10-19 years have a mental disorder, with suicide the third leading cause of death for 15-19-year-

olds in this region.^1,2 Additionally, millions more children and adolescents experience psychological

distress that may not meet the diagnostic criteria for a mental disorder but which has significant

impacts on their health, development and well-being. Poor mental health can have profound impacts

on the health, learning and participation of children and adolescents, limiting opportunities for them

to reach their full potential.

Despite this burden, there is a substantial unmet need for mental health and psychosocial support

(MHPSS) for children and adolescents. Globally, government expenditure on mental health accounts

for only 2 per cent of the total health expenditure⁵ despite accounting for 7 per cent of the total burden

of disease.⁶ In low- and middle-income countries, the estimated ratio of mental health specialists

with expertise in treating children and adolescent is <0.5 per 100,000 population, and there are

fewer than two outpatient facilities for child and adolescent mental health per 100,000 population.⁵

To address the mental health and psychosocial well-being of children and adolescents there is a need

for a holistic and tiered approach to MHPSS that includes actions to: promote well-being; prevent

poor mental health by addressing risks and enhancing protective factors; and ensure quality and

accessible care for those with mental health conditions. This requires mobilization of all sectors -

including health, education, social welfare and justice - as well as engagement with communities,

schools, parents, service providers and children and adolescents themselves.

To support the urgent need to strengthen MHPSS systems and services for children and young

people in the region, especially in the wake of COVID-19 that has had a profound impact on mental

health, UNICEF embarked on a research initiative to identify how MHPSS can be most effectively

implemented. Supported by the Regional Technical Advisory Group (TAG) comprising UNICEF,

UNESCO, WHO and the Global Social Service Workforce Alliance (GSSWA), this initiative included

the development of a regional conceptual framework that set out: a tiered and multisectoral package

of MHPSS services to meet the specific needs of children and adolescents; the roles of key sectors -

health, education, social welfare and justice - in the delivery of this package; and the legislative, policy,

institutional and capacity building steps required to ensure a multisectoral mental health system.

Key to this research initiative was the application of this conceptual framework in four countries in

the region - Malaysia, Papua New Guinea, the Philippines and Thailand - to explore how MHPSS

could be implemented across diverse contexts.

This report documents the application of the conceptual framework in Malaysia and provides country

specific recommendations for strengthening the provision of MHPSS for children and adolescents.

Children and adolescents aged 0-18 years in Malaysia experience a high burden of poor mental

health. Around 1 in 8 adolescents aged 10-19 and 1 in 20 children aged 5-9 years are estimated to

have a mental disorder (including developmental disorder). Suicide is the second leading cause of

death among adolescents aged 15-19. Risk factors for poor mental health - including exposure to

violence, peer victimization and bullying, loneliness and social isolation particularly in the context of

COVID-19 - are also prevalent.

4 Strengthening Mental Health and Psychosocial Support systems and services for

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In response to these needs, Malaysia has made important progress to address child and adolescent

mental health. National policy and legislative frameworks are broadly supportive, recognizing, at least

in part, the specific needs and considerations for this age group and the importance of a national

multisectoral approach to mental healthcare, prevention and promotion. While a large focus of the

current response has been on the clinical management of mental health conditions through the

health sector, there are also important national approaches to improve and respond to mental health

in schools, including through programmes to support early identification, screening, and counselling.

The social welfare and justice sectors also deliver multidisciplinary programmes to identify and

support children and families at increased risk, including those who have been exposed to violence,

abuse or neglect, and children in conflict with the law.

Despite this progress, this analysis has identified some important gaps in the current MHPSS response.

These include the accessibility and availability of child- and adolescent-friendly multidisciplinary

care for mental health conditions (particularly outside specialized tertiary and institutional settings),

comprehensive and coordinated whole-of-education approaches to mental health promotion (including

a national curriculum to support social and emotional learning), a national (and targeted) approach to

support nurturing and responsive care provided by parents and carers, and coordinated programmes

to support healthy peer relationships and address peer victimization. There are also important gaps in

relation to programmes reaching marginalized, out-of-school and migrant children and adolescents.

There are, moreover, some important cross-cutting challenges impacting on implementation of

MHPSS. While mental health and well-being is integrated to some degree in the sectoral plans

of education, social welfare and justice, these generally focus narrowly on specific actions (such

as mental health screening or provision of counselling) rather than encompassing a more holistic

vision for mental health and well-being and clear articulation of the sector’s role and response. At

a subnational level, the lack of clear plans, guidance and structures to support implementation and

multisectoral collaboration has contributed to limited coordination across sectors. Across all sectors,

insufficient numbers and inappropriate distribution of skilled personnel were noted as a major barrier

to implementation, contributing to heavy workloads, long delays in access to care and inconsistent

delivery of interventions. Limited availability of services that are responsive to the needs of children

and adolescents, particularly at community level, and over-reliance on tertiary and institutional-based

care also contribute to high unmet needs and delays in access to services through the health

and social welfare sectors and time-consuming referral from other sectors. Lack of standardized,

national referral protocols, particularly for referrals arising outside the health sector, also contributes

to delays in access to services and supports, as does the lack of standardized protocols and operating

procedures across agencies for supporting children at high risk. Insufficient budgets for MHPSS-

related programmes, and budgeting processes that do not currently support agenda-based and

cross-sectoral budget planning are also key challenges.

In addition to specific recommendations to strengthen the multisectoral mental health system, there

are a number of overarching recommendations to improve the implementation of MHPSS for children

and adolescents in Malaysia:

1. At national level, the Mental Health Act should be strengthened to more clearly articulate the

specific considerations and protections for children and adolescents, including those within the

mental health system. Consideration should also be given to developing a specific multisectoral

child and adolescent mental health strategy that more clearly articulates the MHPSS actions

across the three tiers of responsive care, prevention and promotion, and details a multisectoral

plan (and coordination structure) for implementation, including cross-sectoral performance

indicators and clear roles, responsibilities and accountabilities of key sectors.

2. The Government should strengthen legislative protections for children and adolescents (including

prohibiting corporal punishment, decriminalizing suicide, addressing discrimination and increasing

protections within justice and institutional settings), and address legislative barriers to accessing

MHPSS (such as mandatory parental consent and barriers for undocumented migrants).

3. Under the leadership of the Ministry of Health, a national, multisectoral steering committee for

child and adolescent mental health should be established, with responsibility for coordinating

policy, implementation and accountability.

Executive summary

Under the Ministry of Health, a cross-sectoral, independent monitoring body should be established

to assess quality, compliance and performance of MHPSS programmes and services.

At district level, the state government should support district offices to develop local, multisectoral

implementation plans, resource allocation and coordination for MHPSS. To support this, consider

establishing district-level, multisectoral subcommittees for mental health and provide capacity

building for district-level decision-makers in mental health.

The Ministry of Health, in consultation with other sectors and technical partners, should strengthen

national, standardized protocols for child and adolescent health across agencies, including:

a. Early identification protocols and validated screening tools for this age group and detailed

guidance on their use in different settings (including consideration of the potential harms

of screening);

b. Referral procedures across sectors;

c. Non-specialist management;

d. Case management of children and adolescents engaged in the child protection and

justice sectors.

e. Greater protections for children in conflict with the law and child victims within the justice

system; and

f. National, quality service standards for child and adolescent mental health services

across sectors.

The Government should include mental health services (including outpatient services) within the

national health insurance programme and increase public resource allocation for mental health

across the tiers of care, prevention and promotion. To support this, consideration should be given

to including mental health as a primary programme, and a minimum-services package (based on

the regional framework) should be defined and costed, with budget allocations and responsibilities

clearly defined across key sectors. The Government could also consider establishing a national

cross-sectoral body or cross-sectoral budget committee on MHPSS to support coordinated and

comprehensive budget requests that align with national MHPSS goals.

The Government, with support from professional associations, training institutions and

development partners, should strengthen the multisectoral mental health and psychosocial

support workforce through:

a. Further in-depth mapping to identify key roles across sectors against the MHPSS priority

actions, and the required competencies and inter-sectoral training needs to support these roles;

b. Development of job descriptions for identified roles and/or integration of MHPSS roles into

the defined scope of practice and performance indicators for key providers across sectors;

c. Integration of child and adolescent development and mental health into the pre-service

training of health professionals, the social service workforce, justice sector workers, teachers

and other school-based staff in alignment with the roles and responsibilities with respect

to MHPSS;

d. Strengthened in-service training in mental health (including continuous education) for health

providers (including non-specialists and community-based workers), social service workers,

justice sector workers, teachers and education staff that is competency-based and aligned

with expected MHPSS roles;

e. Training provided to relevant ministry-level staff from the health, education, social welfare

and justice sectors to support planning and development of the workforce as well as broader

MHPSS programmes;

f. Expansion of the number of posts at national and subnational levels; and

g. Improved supervision and support for MHPSS providers across sectors, including establishing

provider support networks and multidisciplinary teams, improved remuneration, job security

and career pathways, and attention to the mental health needs of providers themselves.

6 Strengthening Mental Health and Psychosocial Support systems and services for

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9. The Ministry of Health, in consultation with other key sectors and academic and development

partners, should improve the collection, use and accessibility of data at national and subnational

levels - including data to identify mental health needs, support planning and implementation,

and track progress. This should include the development of a minimum set of MHPSS-related

indicators harmonized across sectors, including performance indicators related to multisectoral

collaboration, and development of user-friendly platforms (such as a data dashboard) to improve

the access of service providers and communities to mental health data.

10. The Government, development partners and non-governmental organizations (NGOs) should

increase opportunities for children and adolescents to participate in MHPSS policy and

programming, including establishing more formal roles for young people such as representation

on the National Coalition for Mental Wellbeing (NCMW) or national steering committee. The

Ministry of Health should also improve child- and adolescent-friendly mechanisms for providing

feedback on MHPSS programmes and mental health services.

11. The Government, development partners and NGOS should expedite the process of systematic

decentralization of mental healthcare to community-based MHPSS by expanding national and

community-based programmes to address mental health- related stigma and discrimination and

improve mental health literacy (particularly targeting children, adolescents and parents/caregivers).

12. The Government, development partners and NGOs should focus on expanding inter-agency

collaboration and monitoring and evaluation of implementation, outcomes and the impact of mental

health programmes, including improved data and information sharing through digital platforms.

Executive summary

Introduction

The mental health of children and adolescents aged 0-18 years is one of the most neglected health

issues globally. Before COVID-19, the WHO estimated that 10 to 20 per cent of children and adolescents

worldwide experienced poor mental health, with half of mental disorders beginning by age 14.³ In East

Asia and the Pacific, almost 1 in 7 boys and 1 in 9 girls aged 10-19 years have a mental disorder, with

suicide the fourth leading cause of death for 15-19-year-olds in this region.² Additionally, many millions

more children and adolescents experience psychological distress that may not meet the diagnostic criteria

for a mental disorder but which has significant impacts on their health, development and well-being.

Malaysia has more than 9 million children and adolescents aged 0-18 years, making up approximately

28 per cent of the country’s population.² Children and adolescents in Malaysia experience a substantial

burden of poor mental health. Modelled estimates from the Global Burden of Disease (GBD) Study

2019 indicate that mental disorders and self-harm account for 19 per cent of the total burden of

disease among 10-19-year-olds, with suicide the second leading cause of death for 15-19-year olds.¹

The COVID-19 pandemic has heightened the need for MHPSS, with significant impacts on education,

social connectedness, family stressors, inequality and disruption of essential services.

BOX 1. DEFINITIONS OF MENTAL HEALTH

‘Mental health and psychosocial well-being’ is a positive state in which children and

adolescents are able to cope with emotions and normal stresses, have the capacity to build

relationships and social skills, are able to learn, and have a positive sense of self and identity.

‘Mental health conditions’ is a broad term that encompasses the continuum of mild

psychological distress through to mental disorders, that may be temporary or chronic, fluctuating

or progressive. During childhood and adolescence, common mental health conditions include:

difficulties with behaviour, learning or socialization; worry, anxiety, unhappiness or loneliness;

and disorders such as depression, anxiety, psychosis, bipolar disorder, eating disorders,

substance use disorders, conduct disorder, attention deficit/hyperactivity disorder, intellectual

disability, autism spectrum disorder, and personality disorders.

Adapted from The State of the World’s Children 2021, UNICEF, 2021.

Poor mental health can have profound impacts on the health, learning and participation of children

and adolescents, limiting opportunities for them to reach their full potential. This age spectrum

encompasses a time of critical brain growth and development when social, emotional and cognitive

skills are formed, laying the foundations for mental health and well-being into adulthood. In addition

to mental disorders, many risk factors for future poor mental health also typically have their onset

during this developmental stage.^4,5 Poor mental health during the first two decades of life also has

broad implications for communities and societies. The lost human capital from mental disorders

during childhood and adolescence in East Asia and the Pacific is estimated to be US$74.68 billion a

year (expressed in terms of purchasing power parity dollars) - the highest of any region.²

Despite this burden, there is a substantial unmet need for MHPSS for children and adolescents.

Globally, government expenditure on mental health accounts for only 2 per cent of total health

expenditure⁶ despite mental health disorders accounting for 7 per cent of the total burden of

disease.⁷ In low- and middle-income countries, the estimated ratio of mental health specialists with

expertise in treating children and adolescents is <0.5 per 100,000 population, and there are fewer

than two outpatient facilities for child and adolescent mental health per 100,000 population.⁶ There

8 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

are also many gaps and missed opportunities to prevent poor mental health and promote well-being,

with approaches often fragmented and small-scale. In addition to inadequate human and financial

resources, lack of coordination between sectors and substantial stigma remain significant barriers to

ensuring that children, adolescents and their families have access to quality services and support.^2,8

BOX 2. DEFINITION OF MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT

Mental health and psychosocial support (MHPSS) refers to any support, service or action

that aims to protect or promote psychosocial well-being or prevent or treat mental

disorders.

Originally defined by the Inter-agency Standing Committee Reference Group on mental

health and psychosocial support in humanitarian settings, this composite term is now

widely used and accepted by UNICEF, partners and practitioners in development contexts,

humanitarian contexts and the humanitarian-peace nexus. It serves to unite as broad

a group of actors as possible and underscores the need for diverse, complementary

approaches to support children, adolescents and their families.

The focus of this project is primarily on actions required in non-humanitarian settings.

Malaysia has made important efforts to address child and adolescent mental health through the

provision of mental health services, parenting programmes and policy and legislation to protect

children from violence and other forms of harm. However, access to services is still far from universal

and unmet need is prevalent. A greater understanding of how to effectively implement MHPSS for

children and adolescents across multiple sectors is needed to address these gaps.

To ensure the mental health and psychosocial well-being of children and adolescents, there is a need

for a holistic and tiered approach to MHPSS that includes actions to:

Promote well-being;

Prevent poor mental health by addressing risks and enhancing protective factors; and

Ensure quality and accessible care for those with mental health conditions.

This requires the mobilization of all sectors - including health, education, social welfare and justice

- as well as engagement with communities, schools, parents, service providers and children and

adolescents themselves. This multisectoral approach is at the core of UNICEF’s East Asia and Pacific

Regional Conceptual Framework on MHPSS and the Global Multisectoral Operational Framework for

mental health and psychosocial support of children, adolescents and caregivers across settings.^9,10

Introduction

Aims and objectives

To support the urgent need to strengthen MHPSS systems and services for children and adolescents

in East Asia and the Pacific, UNICEF embarked on a research initiative to identify how MHPSS can

be most effectively implemented for those aged 0-18 years. This initiative included the development

of a regional conceptual framework aimed at defining:

A tiered and multisectoral package of services required for child and adolescent mental health

and psychosocial well-being (package of priority actions);

The systems, structures and resources needed to deliver these services;

Multisectoral roles and responsibilities - in health, social welfare, justice and education - and

the role of other relevant ministries/agencies, NGOs, young people and youth organizations,

communities and the private sector; and

The legislative, policy, institutional and capacity building steps required to ensure a multisectoral

mental health system.

While the importance of MHPSS in emergency settings is acknowledged, this project focused

specifically on implementation of MHPSS in non-emergency contexts.

Key to this research initiative was the application of this conceptual framework in four countries in

the region - Malaysia, Papua New Guinea, the Philippines and Thailand - to explore how MHPSS

could be implemented across diverse contexts and in parallel to inform the finalization of the regional

conceptual framework.

BOX 3. OUTLINE OF THIS REPORT

This report provides an overview of the overarching MHPSS regional conceptual

framework and synthesizes the findings of the desk-based review, consultation and

validation workshops, and key informant interviews to describe the:

1. Mental health and psychosocial well-being of children and adolescents: the current

situation (mental health needs, and policy and programming responses);

2. Priority package of MHPSS actions;

3. Recommended sectoral roles; and

4. Recommendations for strengthening the multisectoral mental health system.

Overview of the approach

This project was led by Burnet Institute in partnership with the UNICEF East Asia and the Pacific

Regional Office. A Regional TAG comprising UNICEF, UNESCO, WHO, the GSSWA and sectoral

and child and adolescent health experts provided overall feedback and guidance on the conceptual

framework, project approach and regional findings and recommendations.

An outline of the overall project is provided in Figure 1.

Project aims, objectives and approach

FIGURE 1. OVERVIEW OF THE PROJECT APPROACH

REGIONAL CONCEPTUAL FRAMEWORK FOR MHPSS TO

DEFINE PRIORITY ACTIONS and POTENTIAL SECTORAL ROLES

Existing global and regional guidance and frameworks

Evidence of effective interventions and approaches to address child and adolescent mental health

Expert review and consensus

COUNTRY-LEVEL ANALYSIS (MALAYSIA, PAPUA NEW GUINEA, PHILIPPINES and THAILAND) TO PRIORITISE

ACTIONS, EXPLORE SECTORAL ROLES, AND IDENTIFY SUPPORTS NEEDED TO STRENGTHEN

A MULTI-SECTORAL MENTAL HEALTH SYSTEM

Key informant

Consultation workshop

interviews

Validation workshop

Desk-based review of

with multi-sectoral

to explore sectoral roles,

with multi-sectoral

the current situation for

stakeholders to prioritise

recommendations for

stakeholders to refine

children and adolescents

actions and propose

implementation, and

recommendations

sectoral roles

actions to strengthen a

multi-sectoral system

CONSOLIDATED COUNTRY AND REGIONAL GUIDANCE AND

RECOMMENDATIONS FOR IMPLEMENTATION

Country-level analysis

Country-level analysis was co-led by Burnet Institute and the National Institutes of Health Malaysia,

supported by the UNICEF Country Office and the Country TAG, with oversight by the UNICEF East

Asia and the Pacific Regional Office and Regional TAG.

The specific objectives of the country-level analysis were to:

1. Synthesize existing data to describe the mental health needs of children and adolescents

in Malaysia;

2. Synthesize current policies, services and programmes (government and non-government) related

to child and adolescent mental health to describe approaches, experiences and gaps;

3. Identify barriers and enablers to children and adolescents accessing MHPSS;

4. Define a tiered and multisectoral minimum-services package for MHPSS;

5. Explore how the MHPSS regional framework and package of priority actions can be effectively

implemented, including identifying opportunities and challenges across key sectors (health,

education, social welfare and justice) with particular attention to the systems requirements

(financial, human and governance) needed to support implementation.

12 Strengthening Mental Health and Psychosocial Support systems and services for

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This component included four main activities:

1. Desk-based review

Synthesis and secondary analysis of existing survey data

Priority indicators describing mental health outcomes and risks for children and adolescents aged 0-18

years were identified following a mapping of existing global and regional mental health indicators.

Indicators were populated using available national-level survey data (National Health and Morbidity

(NHMS) 2019¹¹ and NHMS Adolescent Survey 2017)¹² and data disaggregated by age and sex, where

possible. Where data were not available, modelled estimates were sought from the GBD Study 2019.¹

Review and synthesis of available literature

To address the gaps and limitations of survey data, published literature was sought to describe the:

Mental health needs of children and adolescents;

Risks and determinants of mental health and/or psychosocial well-being;

Barriers and enablers to accessing quality MHPSS; and

Evidence of interventions and approaches to address mental health and/or psychosocial well-being.

Articles published in English from January 2010 were sought from Medline, Embase, Emcare

and PsychINFO. The search strategy involved three main concepts: 1) Mental Health, 2) Children

and Adolescents, and 3) Malaysia. For concept 1, Mental Health, search terms included mental

health, psychology, psychosocial care, mental disease, suicidal behaviour, psychotherapy, anxiety

management, and several specific mental diagnoses and psychotherapy modalities. For concept 2,

Children and Adolescents, search terms included child, adolescent, and youth. For concept 3, Malaysia,

search terms included Malaysia, Kuala Lumpur, and several other Malaysian city and state terms,

such as Penang, Selangor, and Johor. This review included all relevant studies, including narrative

reviews, systematic reviews, randomized controlled trials, quasi-experimental trials, observational

studies and case series. Studies were included if they were conducted in Malaysia, included children

and/or adolescents aged 0-18 years, and addressed one or more of the focus areas above.

Search results were uploaded to Covidence. A total of 2,054 studies were imported for screening;

659 duplicates were removed, 1,395 studies were screened and 1,204 were excluded. In total, 191

articles were included for full-text screening and extraction to the literature review as appropriate.

Manual searching of reference lists from relevant articles was also conducted to identify further peer-

reviewed literature or grey literature.

Mapping and review of existing policies, strategies, plans and legislation

Government policies, plans, strategies and legislation were sought from relevant government

websites and United Nations (UN) agencies. Relevant government ministries or departments from

each sector (health, education, social welfare and justice) were first identified and websites searched

using similar search terms to those above to identify potentially relevant documents relating to mental

health. Documents were included if they were:

Produced by the Government, or described a government policy/plan/strategy/legislation;

Related to government intentions, actions, decision-making;

National in scope;

The most recent available;

Addressed one or more tiers of the conceptual framework for MHPSS (care, prevention, promotion).

Project aims, objectives and approach

These were then mapped and reviewed to identify: the sector; the extent to which they included

specific actions for children and/or adolescents aged 0-18 years; conceptual framework tier(s)

addressed; summary of key actions in relation to children and adolescents; and targets and indicators

(where relevant).

2. Country-level stakeholder consultation workshops

Two half-day, online workshops were conducted on 27 and 29 July 2021. These were attended by

72 participants, including representatives from the Government (primarily the health, education,

social welfare and justice sectors), NGOs, the private sector, UN agencies, youth organizations and

young people with hearing impairment. The aim of the workshops was to present and reflect on the

MHPSS conceptual framework, identify priority actions for MHPSS for children and adolescents, and

propose sectoral roles and responsibilities for implementation of the MHPSS package. To facilitate

this, participants were invited to complete an online prioritization tool to provide feedback on each

proposed MHPSS action and indicate a lead sector. Thirty-three participants completed the online

tool, and findings were presented and discussed during the second workshop.

3. Key informant interviews with sector stakeholders

Key informant interviews were conducted to explore in depth:

Perceptions and understandings of priority child and adolescent mental health needs;

Current programmes and approaches related to MHPSS;

Barriers and enablers impacting on implementation;

Recommended sectoral roles and responsibilities; and

Challenges and considerations for strengthening a multisectoral mental health system.

Sector-specific question guides drew on the project conceptual framework and were refined following

review by sectoral and mental health experts through the Regional and Country TAGs.

A total of 25 interviews were conducted with stakeholders aged 18 years and over from the health

(five), education (two), social welfare (10) and justice (four) sectors, including government, non-

government, UN agency and four youth representatives. All interviews were conducted via Zoom

due to COVID-19 restrictions. Interviews were conducted in Bahasa Malaysia or English, facilitated

by experienced researchers who had completed a three-day, intensive training workshop covering

the study objectives, study procedures and ethical considerations. Interviews were audio-recorded

and transcribed verbatim. Transcripts were analysed thematically using a Framework Method.

All participants provided voluntary informed consent. Ethics approval was obtained from the Alfred

Ethics Committee (Australia) and the Ministry of Health Medical Research and Ethics Committee

(Malaysia). Approval was also obtained from the Ministry of Education Malaysia through its Educational

Research Application System (eRAS 2.0).

4. Translational workshop

Following data analysis, a second, one-day workshop was conducted with 27 participants from the

Country TAG and other key sectoral stakeholders. The purpose of this workshop, held in person and

online, was to present and reflect on the key findings and refine the recommendations through

facilitated small group discussions.

Further details on the workshops, prioritization tool and interview guide are provided in Appendix A.

14 Strengthening Mental Health and Psychosocial Support systems and services for

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Limitations

The Malaysia analysis has some key limitations. First, the synthesis of peer-reviewed literature was

restricted to studies published in English. However, key publications in Bahasa Malaysia relating to the

criteria above were identified and reviewed by Institute for Clinical Research researchers for inclusion

in the desk review. Not all policy/strategy/legislation documents were able to be accessed online -

these gaps were filled through key informant interviews. Despite this, some key policies may not have

been included. Additionally, the desk review was limited to national and high-level policies - specific

details regarding protocols, guidelines, training programmes and standard operating procedures in

relation to MHPSS were not included. Similarly, key informant interviews were limited primarily to

national-level stakeholders, so some specific approaches, priorities and challenges at subnational

level may not have been explored in depth. This project also focused intentionally on supply-side

priorities and challenges with respect to implementing MHPSS. Representatives from youth-focused

organizations and networks were included in workshops and interviews to provide perspectives on

demand-side barriers, enablers and service delivery preferences. However, further research is needed

to explore these issues in more depth with children, adolescents and their parents/carers (including

those with lived experience).

Project aims, objectives and approach

The first phase of the project developed a regional conceptual framework for MHPSS for children and

adolescents. The framework was developed through: a review and synthesis of existing global and

regional frameworks for mental health and evidence for effective interventions; a review and expert

consensus provided by the Regional TAG and external content experts; and a review and feedback

from the four Country TAGs and Malaysia stakeholders during consultation workshops. Details are

provided in Appendix B.

An important foundation for this framework is the UNICEF Global Multisectoral Operational

Framework for mental health and psychosocial support of children, adolescents and caregivers across

settings.¹⁰ The Global Framework defines a range of interventions to promote psychosocial well-

being and prevent and manage mental health conditions, providing guidance to support planning

and implementation. While the inception of this research initiative pre-dated the finalization of the

Global Framework, the regional framework has sought to include and harmonize key actions for

MHPSS in East Asia and the Pacific with the global guidance. The purpose of the regional framework

is specifically to define the MHPSS actions that are a high priority for East Asia and the Pacific and

provide detailed guidance to support implementation, with a focus on describing sectoral roles and

recommendations to strengthen a multisectoral mental health system.

Guiding principles of the framework

Aligned with the Global Multisectoral Operational Framework, the regional framework adopts a

socioecological approach to addressing MHPSS, recognizing that the mental health and well-being of

children and adolescents is profoundly influenced not only by individual attributes and experiences,

but also by relationships with family, peers, communities and the broader environment within which

children grow, learn and socialize. The framework also considers mental health and well-being

across the life course, recognizing childhood and adolescence as critical periods of cognitive, social

and emotional development, with implications for mental health and well-being that extend into

adulthood and the next generation. Responses to mental health needs and risks need to be adapted to

developmental stages and needs, rather than based on a rigid application of biological age. Responses

should furthermore consider the cumulative impacts of risks (or protective factors) across the life

course. Finally, the framework also acknowledges that there are significant gendered differences in

risks, experiences, care-seeking behaviours and outcomes with respect to mental health. Children

with disabilities also experience unique mental health needs and barriers to accessing MHPSS.

Responses, therefore, must take specific measures to ensure that MHPSS is gender-responsive,

accessible, inclusive and seeks the active participation of children, adolescents and their families.

A regional framework for MHPSS for children and adolescents in East Asia and the Pacific

A regional framework for child and adolescent MHPSS

The regional framework defines three key tiers of actions required to ensure the mental health and

well-being of children and adolescents, with systems strengthening as a cross-cutting theme (see

Figure 2).

FIGURE 2: KEY TIERS OF MHPSS ACTIONS FOR CHILDREN AND ADOLESCENTS

RESPONSIVE CARE

Clinical

care

Sub-clinical

care

Targeted

PREVENTION

prevention

Universal

prevention

MENTAL HEALTH

PROMOTION

Ensuring an enabling

and safe environment

Within each of the three tiers are domains of action:

Responsive care for children and adolescents with mental health

conditions

This includes care that is age- and developmentally appropriate, gender and disability-inclusive and

non-discriminatory. Key actions include:

Screening, assessment and early identification of mental health needs to identify children and

adolescents who are at risk or have mental health conditions, with a focus on those who would

most benefit from care. It also includes the referral pathways (between and within sectors) for

those requiring specialized care or social support and protection, noting that screening in the

absence of referral and accessible care can be stigmatizing.

Management/treatment that is responsive to the needs of children and adolescents, including

care that is developmentally appropriate, accessible, comprehensive and culturally appropriate,

including for:

- Clinical mental disorders, which refers to a clinically diagnosable disorder generally made

according to the classification systems of the Diagnostic and Statistical Manual of Mental

Disorders (5th edition) or the International Classification of Diseases.

- Subclinical mental disorders and mental health conditions, when children and adolescents

show the signs or symptoms of a mental or psychological disorder that is below the clinical

threshold for mental disorder.

18 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Continuing care. Mental health typically fluctuates for individuals over their life cycle. For those

with identified needs, these may increase or decrease over time and may be exacerbated by

stressful life events. Continuing care (that ensures accessible care and support as required)

is essential to ensuring the best outcomes for children and adolescents, as well as optimal

outcomes across the life course.

Prevention of mental health conditions in the immediate social

context

These actions aim to address risk factors for poor mental health and enhance protective factors. These

can be universal (that is, applicable to all children and adolescents, for example limiting access to

alcohol and other drugs), or targeted (focused on children and adolescents with high-risk behaviours

or in high-risk settings, for instance interventions to address harmful substance use). They include

four groups of interventions, coarsely mapped against the socioecological framework:

Building the individual assets of children and adolescents, aimed at fostering individual-level

assets (physical health, intellectual development, psychological and emotional development and

social development). This includes a focus on social and emotional learning, building resilience

and improving mental health literacy in children and adolescents.

Strengthening positive peer support (including online), given that peer relationships are

a critical protective factor for good mental health. This also includes addressing harmful peer

relationships (online and offline), including bullying and victimization (including cyberbullying).

Psychosocial competence building for parents/carers, including positive parenting practices

and improving their skills in responsive and nurturing caregiving. This includes a focus on

preventing harmful parenting, as well as addressing parental mental health.

Safe and enabling learning environment that ensure a prosocial environment in a setting

where children and young people are connected, supported and not subject to harmful exposures

(including all forms of physical or mental violence, injury and abuse, discrimination and exclusion,

neglect or negligent treatment, maltreatment or exploitation, including online sexual exploitation

and abuse).

Ensuring a safe and enabling environment to promote mental

health

These actions seek to address the structural determinants of mental health and well-being in relation

to where children and adolescents live, grow and learn through policy and legislation, and community

engagement. The determinants of psychosocial well-being are very broad, encompassing factors

such as secure housing, the environment and climate change, poverty, nutrition, social justice and

equality, disaster, conflict, economic and fiscal contexts, and political contexts. Following consultation

with the Regional TAG and expert advisors, this tier of the framework was narrowed to specifically

focus on actions in relation to:

Community engagement and participation - the active involvement of people from

communities, including young people and those with lived experience of poor mental health,

in the process of planning, delivering, monitoring and evaluating policies and programmes, and

in mental health advocacy. The involvement of community members is essential to determine

their own priorities in dealing with mental health conditions with respect to cultural context.

Community engagement is also central to addressing harmful norms, attitudes and beliefs that

contribute to poor mental health (for example, discriminatory attitudes towards non-conforming

gender identity or expression), that contribute to poor care-seeking behaviours (for example,

harmful norms around masculinity that discourage seeking help), and to stigma and discrimination

against children and adolescents with mental health problems.

A regional framework for MHPSS for children and adolescents in East Asia and the Pacific

Policy and legislation that both enables and protects the rights of children and adolescents with

mental health conditions, protects children and adolescents from the harms and risks associated

with poor mental health, and provides a clear framework for the system and sectoral roles in

responding to and supporting mental health, including sufficient allocation of public resources for

MHPSS. Legislation should reflect the values and principles of human rights and the Convention

on the Rights of the Child (CRC), with the best interests of children and adolescents as a primary

consideration. This includes, but is not limited to, the right to equality and non-discrimination,

dignity and respect, privacy and individual autonomy, and information and participation.¹³

In addition to identifying what ‘actions’ are required within each of these tiers, the framework also

describes broad roles for key sectors in implementing MHPSS for children and adolescents (see Figure

3). The specific roles and responsibilities of each sector were explored in depth during country-level

analysis; however, the regional framework proposes broad overarching roles:

The health sector plays a central role in ensuring accessible and responsive mental health services

for children and adolescents with mental health conditions. This includes the delivery of early

identification, screening, referral and management by non-specialist providers (general practitioners,

nurses, midwives, community health workers and volunteers, and auxiliary health providers) through

to specialized care for severe or complex cases provided by child and adolescent psychiatrists,

mental health nurses, neurodevelopment and behavioural paediatricians, clinical psychologists,

occupational therapists and speech therapists. The health sector may also play an important role in:

targeted prevention for those at risk of poor mental health (for example, the provision of preventive

interventions for children and adolescents with comorbid health conditions, those identified to have

risk behaviours such as substance use and those in high-risk settings, as well as support for positive

parenting and parents with mental health conditions); and mental health promotion (for example,

increasing mental health literacy, and addressing harmful norms and stigma). The health sector may

furthermore play an overall leadership and advocacy role in MHPSS given that the health service

plays a key role in mental health service provision.

The social welfare sector plays a significant role in the delivery of MHPSS. The social service

workforce broadly encompasses government and non-government professionals, paraprofessionals

and community volunteers who not only work within social welfare or community development but

may also be employed by other sectors (including health, education and justice). Because of the

particular focus on child protection and working with families at risk, this sector plays a crucial role to

play in the delivery of targeted, preventive interventions to address key risk factors, in particular for

children and adolescents and their families with high-risk exposure to poor mental health (for example,

those exposed to violence, neglect or exploitation). This also includes delivering and supporting

programmes to improve responsive and nurturing caregiving, which may be universal or targeted to

those at increased risk (such as parents with mental health conditions). This sector also has a key

role in early identification and screening in some settings, supporting a strong referral system and

providing responsive care for mental health conditions as part of a multidisciplinary team. There is

also a broader opportunity to ensure an enabling environment for good mental health through social

welfare and social protection that addresses the social determinants of health. The social welfare

sector may additionally play a key role in community-based and national advocacy that can help to

address stigma and harmful norms.

The education sector is critical for implementation of universal preventive interventions as well as

ensuring that school and learning environments promote mental health and well-being. The education

sector arguably comprises the biggest mental health and psychosocial support workforce as teachers,

school-based counsellors and psychologists, and volunteers (such as peer counsellors) have the

potential to reach large numbers of children and adolescents. In addition to delivery of curriculum-

based approaches to support social and emotional learning, there is also an opportunity for schools

to shape attitudes and norms around mental health and positive relationships that are an important

contributor to building an enabling environment for good mental health. Teachers, school counsellors

and school-based psychologists can also play a role in early identification and assessment of mental

health needs, referral, behavioural management and targeted prevention. Schools furthermore have

an important role to play in supporting children and adolescents with mental health needs, including

through ongoing opportunities for education as well as providing alternative learning pathways.

20 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Schools may also provide an opportunity for screening, with careful consideration; screening alone,

in the absence of accessible services and support, can be stigmatizing. Additionally, lack of age,

cultural and language-validated tools, limited training in their application and lack of confidentiality

may contribute to misdiagnosis, pathologizing normal behaviours, and stigma.

The justice sector also has a significant role in supporting children and adolescents at increased risk

of poor mental health, including those who are in conflict with the law and those who are victims

(or witnesses) of violence. This includes responding to existing mental health needs and risk factors

(such as exposure to violence and substance misuse) for children in conflict with the law, as well

as preventing (or responding to) further harms and risks exacerbated by detention. In collaboration

with the social welfare and health sectors, police, public prosecutors, court psychologists, probation

officers, detention centre workers, social service workers and judges could support the delivery of

early identification and screening in some settings, as well as referral and linkages with mental health

services and targeted prevention and response in justice settings (including addressing the harmful

use of substances and programmes to build individual assets and skills).

FIGURE 3. SUMMARY OF BROAD SECTORAL ROLES FOR MHPSS.

Health

Social welfare

Education

Justice

sector

1 Clinical

2 Subclinical

3 Targeted prevention

4 Universal prevention

5 Ensuring environment

Darker shade indicates where a sector should have a leadership role or primary responsibility for

implementation, by tier of action.

Finally, the regional framework also identifies eight pillars of systems strengthening that are required

to enable effective and equitable implementation of these actions within and across key sectors

(see Figure 4).

A regional framework for MHPSS for children and adolescents in East Asia and the Pacific

FIGURE 4. PILLARS OF SYSTEMS STRENGTHENING

*To promote an enabling environment, providing the legal and

Legislation

regulatory frameworks required to support implementation of

MHPSS, and policies and plans to strengthen systems and

and policy

services delivery

*To enable coordination within and across sectors, between

Leadership

levels of government, and with non-government and informal

and

service providers, with clearly defined roles, responsibilities

governance

and accountability

*Modules of delivery to ensure services are equitable, inclusive,

Service

accessible to all, and age / developmentally appropriate. Includes

delivery

identifying what actions can be integrated into existing platforms

and what new models / platforms are required

Standards

and

*To support quality assurance and accountability

oversight

*The multisectoral mental health workforce (across health, education,

Workforce

social welfare and justice), with defined roles, competencies, training

and supervision

Budget and

*Adequate allocation and expenditure of resources and financing

financial

mechanisms to ensure equitable access and quality of services

resources

*Engagement and participation of children adolescents, families and

Participation

communities in planning, design, delivery and evaluation of MHPSS

Data,

*Mechanisms for collection, analysis and dissemination of reliable

information

and timely information to support planning, implementation and

monitoring and evaluation

and research

22 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Mental health needs of children and

adolescents

Mental health outcomes for children and adolescents

Children and adolescents aged 0-18 years in Malaysia experience a substantial burden of poor mental

health. Modelled estimates from the GBD Study 2019 indicate that mental disorders and self-harm

account for 19 per cent of the total burden of disease among 10-19-year olds.¹ Among younger

adolescents and children aged 5-14 years, mental disorders are the leading cause of poor health,

with conduct disorder, anxiety disorder and depression alone accounting for 12 per cent of the total

burden of disease in this age group.¹ Around 1 in 8 adolescents aged 10-19 and 1 in 20 children aged

5-9 are estimated to have a mental disorder (including developmental disorder).¹

Figure 5 shows the modelled burden of disease due to mental disorders across childhood and

adolescence, reported as disability-adjusted life years (healthy years of life lost due to either disability

(illness) or premature death). Several important observations can be made. First, the burden of disease

due to mental disorder increases substantially during childhood and adolescence, with the greatest

increases happening during later childhood and early to mid-adolescence. Second, the specific causes of

poor mental health vary substantially by age: for young children, developmental disorders predominate;

for young adolescents there is a sharp increase in conduct disorders and depression and anxiety;

for older adolescents and young adults there is a pre-dominance of depression and anxiety, with an

emergence of psychosis and eating disorders. Third, there are important differences in burden and

pattern of mental disorder by gender. Girls have an overall larger burden of mental disorder that is

mostly driven by excess depression and anxiety, while boys have an excess burden of conduct disorder.

FIGURE 5: DISEASE BURDEN DUE TO MENTAL HEALTH DISORDERS ACROSS CHILDHOOD AND

ADOLESCENCE IN MALAYSIA (IN DISABILITY-ADJUSTED LIFE YEARS (DALYS) - YEARS OF LIFE LOST

TO EITHER CAUSE-SPECIFIC DEATH OR DISABILITY)

Malaysia

Female

Male

2200

2000

1800

1600

1400

1200

1000

800

600

400

200

1 to 4

5 to 9

10 to 14

15 to 19

1 to 4

5 to 9

10 to 14

15 to 19

Anxiety disorders

Depressive disorders

Bipolar disorder

Eating disorders

Schizophrenia

Conduct disorder

Autism spectrum disorders

Idiopathic developmental intellectual disability

Attention-deficit/hyperactivity disorder

Other mental disorders

Source: IHME GBD 2019.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Limited primary survey data for child and adolescent mental health in Malaysia also highlight a substantial

burden of needs. The most robust mental health data come from the NHMS 2019 and NHMS Adolescent

Survey 2017.^11,14,15 Overall, the proportion of children aged 5-15 with reported mental health symptoms

increased from 13.0 per cent in 1996 to 20.0 per cent in 2011, before falling to 12.1 per cent in 2015 and

7.9 per cent in 2019.^11,16,17 The highest reported prevalence of mental health conditions among 5-15-year-

olds in the 2019 NHMS was in Perak state at 19.9 per cent, and prevalence was also higher in rural

areas and in the lowest-income households.¹¹ The 2017 NHMS survey also found that 17.7 per cent of

adolescents reported depressive symptoms,¹⁴ while 2019 analysis of NHMS data estimated that 39.7

per cent of Malaysian adolescents experienced anxiety symptoms.¹⁸ One in 14 adolescents reported

anxiety so severe it disrupted their sleep most or all of the time (see Figure 6).¹⁴

FIGURE 6: PREVALENCE OF SIGNIFICANT WORRY FOR 13-17-YEAR-OLDS, MALAYSIA

Proportion of 13-17-year-olds who report being mostly or always so worried that they can't

sleep at night in the last 12 months (%)

Both

Female

Male

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

Source: NHMS 2017.

In younger age groups, the NHMS 2019 found that 15.9 per cent of children displayed conduct

problems, 4.6 per cent displayed hyperactivity problems and 8.3 per cent emotional health problems.¹¹

A separate 2019 longitudinal study conducted in the Malaysian cities of Petaling and Klang among

children aged 7-8 and 13-14 reported that between 8.5 and 9.3 per cent of children displayed

emotional and behaviour problems, according to parents and teachers.¹⁹ Both studies found significant

gender differences, with boys more likely to have reported conduct and hyperactivity problems and

girls more likely to have reported emotional health problems.^11,19

Suicide is closely related to poor mental health. The proportion of adolescents reporting suicidal

ideation appears to be increasing: from 7.9 per cent in the 2012 Global Student Health Survey (GSHS)

to 10.0 per cent in the 2017 NHMS Adolescent Health Survey (although the two sources are not

perfectly comparable).¹⁴ The 2017 NHMS Survey also found that 7.3 per cent of adolescents reported

making suicide plans and 7.0 per cent reported a suicide attempt in the previous 12 months (see

Figure 7). This was higher than in comparable countries such as Indonesia and Brunei, but lower than

in Thailand.¹⁴ Girls were more likely to report suicidal ideation (10.8 per cent versus 9.1 per cent) and

suicidal plans (7.8 per cent versus 6.8 per cent). Suicide attempts were similar between boys and

girls at 7.0 per cent and 6.9 per cent, respectively.¹⁴

26 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

FIGURE 7: SUICIDAL BEHAVIOUR SELF-REPORTED BY ADOLESCENTS, MALAYSIA

Proportion of 13-17 year-olds who report suicidal behavior in the last 12 months

Suicidal ideation

Suicide plan

One or more suicide

attempts

Both Female Male

Source: NHMS 2017.

Suicide is estimated to be the second leading cause of death for adolescents in Malaysia.¹ Direct

information about suicide mortality among adolescents and children in Malaysia is sparse.²⁰ The

National Suicide Registry Malaysia reported that in 2009 the suicide mortality rate was 1.03 per

100,000 population. This was relatively low compared to other Asian countries, and this may have

been due to under-reporting related to stigma and the legal implications of suicide under Malaysian

law.²⁰ Fifty-three young adults aged 15-24 were reported to have died by suicide,²⁰ making them

the most represented age group in suicide figures, at 16.2 per cent.²¹ More age-specific data were

not provided. Risk factors for suicide were male gender and Indian ethnicity. Most adolescents who

died by suicide did not have a known past history of attempted suicide, physical and mental health

problems or family history of suicide.²⁰ There are no more recent data as the National Suicide Registry

was discontinued in 2009.²² Hospital figures are another useful data source. In 2014, there were

83 admissions to hospital for intentional self-harm, at a rate of 0.3 per 100,000 of the population.²²

This too was likely an underestimate.²³ Adjusting for missing data (e.g., deaths not reported) or

misclassification of cause of death, the GBD 2019 estimated that the mortality rate due to suicide

for children aged 10-14 was 0.16 per 100,000 population, and for adolescents aged 15-19 it was 3.13

per 100,000 population (see Figure 8). Adolescent boys had around four times the mortality rate due

to suicide compared with girls.²⁴

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

FIGURE 8. SUICIDE MORTALITY AMONG 10-24-YEAR-OLDS, MALAYSIA

Malaysia

5.0

Southeast Asia,

East Asia, and Oceania

4.5

Female

Male

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

10 to 14

15 to 19

Source: IHME GBD 2019.

Available survey data and published studies of mental health needs in Malaysia most commonly

relate to mental disorder. To explore broader understandings of mental health needs during childhood

and adolescence, stakeholders who participated in interviews and workshops were also asked to

describe their own understanding of mental health during this age period. While stakeholders from the

health, education, social welfare and justice sectors identified mental disorders (depression, anxiety,

personality disorder, post-traumatic stress disorder and bipolar disorder) as the most important mental

health issues for this age group, young people themselves had a more holistic understanding of

mental health and well-being. For young people, the focus of needs was on mental health-related

stigma, neglect from parents, and mental health issues being mistaken for growing pain or phases of

puberty. The health and social welfare sectors also identified self-harm and suicide as priority mental

health outcomes and child and sexual abuse as key contributors to poor mental health. The justice

sector highlighted substance abuse and its associated criminal implications as an important mental

health need among this age group.

28 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Risks and determinants of mental health and psychosocial

well-being

UNICEF’s The State of the World’s Children 2021 report defines three spheres of influence that shape

the mental health and well-being of children and adolescents. These are the ‘world of the child’

(individual assets, parents, carers and families), the ‘world around the child’ (safety, security and

healthy attachment in the school, community and online), and the ‘world at large’ (social determinants,

including poverty, disaster, conflict, discrimination and migration) (see Figure 9).² Childhood and

adolescence are periods of rapid change in social context and roles, and the timing and nature of

exposures from the environment and immediate social context can powerfully shape mental health

and well-being for children and adolescents across their lives. These risks and protective factors are

cumulative across the life course and are often clustered - with children who experience multiple

adverse childhood experiences (abuse, neglect, violence or dysfunction within families, peers or the

community) having the highest risk of poor mental health.²

FIGURE 9. SPHERES OF INFLUENCE ON MENTAL HEALTH AND PSYCHOSOCIAL WELL-BEING

WORLD OF THE CHILD

 Individual assets and

behaviours

 Parents, carers, families

WORLD AROUND THE CHILD

 Safety, security and healthy

attachment in schools,

community and online

WORLD AT LARGE

 Social determinants

(poverty, disaster, conflict,

discrimination, migration)

Source: Adapted from UNICEF’s The State of the World’s Children 2021² report.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

The world of the child

For children, healthy attachment with parents and other caregivers and nurturing, responsive

care are powerful determinants of mental health and well-being. Attachment is the emotional

relationship between a child and their parents or caregivers that gives a child a sense of safety and

protection and fosters the development of social and emotional skills. While attachment is crucial

and evolves during the course of childhood and adolescence, it is one of the defining influences

on mental health and well-being during infancy and early childhood.² The mental health of parents

and caregivers also impacts on their capacity to provide responsive care and healthy attachment,

including for adolescent parents.²⁵

There are currently no national-level data or subnational studies describing parental attachment,

positive parenting, early stimulation or adequate supervision during childhood in Malaysia. There

are, however, an estimated 13,000 children and adolescents living in approximately 90 private and

35 government-run orphanages throughout Malaysia.^26,27 A study of 287 adolescents aged 12-17 in

six orphanages in the Klang Valley found that 72.5 per cent had moderate to very severe depression

and 71.1 per cent had moderate to very severe anxiety. A total of 70.8 per cent and 69.2 per cent

reported low self-esteem, and this was significantly associated with depression, anxiety and stress.²⁸

Violence and neglect experienced within households and families are key risk factors for mental

health conditions.^29,30 The 2016 NHMS reported that 71 per cent of children aged 1-14 years had

experienced violent discipline by caregivers (psychological aggression and/or physical punishment).

In addition, 11.8 per cent of adolescents reported recent physical abuse at home and 43.2 per cent

reported verbal abuse.¹⁴ Both physical and verbal abuse at home have been associated with suicidal

ideation.³¹

For adolescents, substance use and misuse are important individual-level risk factors for poor mental

health.³² The NHMS 2017 reported that 2.8 per cent of adolescents aged 13-17 years had ever used

marijuana (see Figure 10), and 2.4 per cent had ever used amphetamines or methamphetamines, with

prevalence higher among boys than girls. However, there were no other data or studies describing

substance use among this age group or its impacts on mental health.

FIGURE 10: MARIJUANA USE, MALAYSIA

Proportion of 13-17 year-olds who report lifetime marijuana use (%)

Both

Female

Male

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Source: NHMS 2017.

Sedentary behaviours and screen time are also important, individual-level influences on psychosocial

well-being. In the 2017 NHMS Adolescent Survey, only 19.8 per cent of 13-17-year-old school-going

adolescents were physically active for at least 60 minutes five days per week, and 50.1 per cent spent

at least three hours per day on sedentary activities. In the same survey, overall internet addiction

prevalence was 29.0 per cent. The highest prevalence was found in the capital Kuala Lumpur at

39.2 per cent.¹⁴ A separate study of 178 students from 56 primary schools across the Klang Valley,

Selangor, found internet addiction prevalence of 23 per cent.³³ A 2019 study of 396 students in

30 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Chinese primary schools in Johor Bahru found that excessive internet usage was associated with

anxiety symptoms.³⁴ A study of 158 students aged 13-16 found that smartphone addiction affected

51.9 per cent of participants, and this was significantly correlated with poor mental health.³⁵

Children and adolescents with chronic illness and disability may also experience a higher burden

of poor mental health. While these children were noted by stakeholders during interviews as having

an excess burden of poor mental health, there are currently no data available describing their mental

health needs.

Child marriage and early pregnancy are associated with poorer mental health outcomes. In

Malaysia, 5 per cent of girls aged 15-19 years are currently married, and there are 13 births per 1,000

girls in this age cohort per year.³⁶ While studies exploring the mental health of married Malaysian

adolescents are limited, studies of maternal mental health report that young mothers (under 20 years)

have a higher risk of anxiety compared with older women.³⁷

Children and adolescents living in alternative care, including residential care, are also at

increased risk of poor mental health and exposure to risk factors, such as violence. Residential child

care is managed by the Department of Social Welfare as well as NGOs (licenced by the Department).

In 2019, Department statistics reported that 6,382 children were in need of care and protection, of

which 4,043 were girls. Around 1,100 children were in an institutional residential care facility.³⁸ There

are very limited data describing the mental health needs or risks for children in residential care. Small

studies have reported higher rates of behavioural problems, depression and anxiety among children

in care compared to those living with parents,³⁹ and exposure to verbal aggression among peers and

use of shame by caregivers.⁴⁰

The world around the child

in addition to healthy parent/carer relationships, peer relationships and connectedness also

influence mental health and well-being, particularly during adolescence. In the 2017 NHMS, 9.3

per cent of adolescents reported feeling lonely most of the time or always (see Figure 11), with the

percentage higher among girls than boys. This represents an important target for action.

FIGURE 11. PREVALENCE OF LONELINESS AMONG 13-17-YEAR-OLDS, MALAYSIA

Proportion of 13-17 year-olds who reporting feeling lonely most of the

time or always in the last 12 months (%)

Both

Female

Male

Source: NHMS 2017.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Exposure to bullying behaviour,ⁱ harassment and violence are risk factors for poor mental health

and these are highly prevalent among adolescents in Malaysia (see Figure 12). In 2017, 16.2 per cent

of adolescents reported having recently been victims of bullying behaviour.¹⁴ Witnessing, perpetrating

or being the victim of physical violence is also common, with more than a quarter of 13-17-year-olds

reporting having been physically attacked in the last 12 months. Rates were higher among boys, with

31.4 per cent reporting being physically attacked compared with 19.3 per cent of girls (see Figure

12).¹⁴ Adolescents who are lesbian, gay, bisexual, transgender, intersex, or queer/non-conforming

also experience very high rates of peer victimization and violence in the context of substantial

stigma. These adolescents have reported widespread verbal humiliation and violence. Systemic

discrimination has also been significant, with reports of school expulsion of lesbian and bisexual

youth, and transgender students forced to dress in clothes that did not match their gender identity.⁴¹

Violence against transgender children at home and in school has also led to early school dropout.⁴¹

FIGURE 12. BULLYING (A) AND VIOLENCE (B) AMONG 13-17-YEAR-OLDS, MALAYSIA

Proportion of 13-17 year-olds who report being bullied in the last month (%)

Both

Female

Male

Proportion of 13-17 year-olds who report being physcially attacked in the last 12 months (%)

Both

Female

Male

Source: NHMS 2017.

Sexual harassment, sexual violence and intimate partner violence are also important risk factors,

most notably for adolescent girls. However, national-level data reporting intimate partner violence

experienced by adolescent girls in Malaysia are lacking. Around 3 per cent of adolescent girls aged

15-19 years have ever experienced sexual violence from a non-intimate partner.³⁶

Safe and enabling learning environments profoundly influence mental health and well-being.

Participation in early education, primary and secondary school are important protective factors.

Available data indicate that the majority (99 per cent) of children in Malaysia are enrolled in organized

early childhood education and primary education; however, 12 per cent of 12-15-year-olds are not

attending secondary school. Out-of-school children and adolescents were identified by stakeholders

as at high risk of poor mental health due to poor access to school-based MHPSS services and a

The term ‘bullying’ is used here as it is consistent with the survey measures referenced. However, it is noted that there is an emerging

approach to redefine bullying as ‘unhealthy relationships or situations’ with a focus on the behaviour itself, its determinants and impacts,

rather than on the child.

32 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

clustering of other risk factors (such as substance use, family conflict and violence). Children with

developmental disorders or disabilities were also identified as experiencing excess risks for poor

mental health in school settings, where resources to support them and their teachers are limited.

Schools can also be a source of stress. Stakeholders (including young people) described academic

pressures, competition, and family expectations around academic performance as contributing to

high levels of psychological distress among students, particularly in secondary school.^16,42 These

stresses were exacerbated during the COVID-19 pandemic due to the increased pressure of remote

learning coupled with social isolation and the loss of peer support. Schools can also be a setting of

violence and harassment, with high rates of bullying experienced among school students and corporal

punishment and verbal abuse by teachers.

The world at large

National-level data and published studies exploring the association of social determinants with child

and adolescent mental health in Malaysia are limited. However, stakeholders identified several factors

that are likely to influence mental health and well-being. These include poverty and economic instability

(exacerbated by the COVID-19 pandemic), and legislative and other barriers that limit access to MHPSS.

Malaysia hosts over 182,000 asylum seekers and refugees, the vast majority from Myanmar. An

estimated 44,800 are below 18 years of age.⁴³ Due to the lack of a domestic legal framework for

management of refugees, their irregular status renders them liable to prosecution under the Immigration

Act. Refugees continue to be at risk of arrest, prosecution, detention and, in some cases, deportation.

This uncertainty and fear contribute to significant psychological distress,⁴² which is compounded by past

traumatic experiences in their country of origin. A 2021 survey of 91 refugee adolescents in Malaysia

found that discrimination was pervasive and occurred in a range of settings.⁴⁴

Stigma and discrimination are also significant determinants of mental health. Misconceptions and

stigma associated with mental health are common and were noted by stakeholders as an important

contributor to poor mental health and poor access to MHPSS. For adolescents in particular, stigma

and discrimination experienced by those whose sexuality and/or gender identity do not conform to

rigid norms also contributes to a high burden of poor mental health.⁴¹

A more recent threat to mental health is COVID-19. Public health approaches that limit social

interactions and disrupt education and employment (and the resultant isolation and increased use of

social media and a potential increase in exposure to family violence and conflict) have acute impacts

on mental health, while the economic uncertainties and projected socioeconomic inequalities have

more long-term implications.⁴⁵ These disasters can also result in a diversion of resources away from

mental health services, and combined with greater need, can lead to greater difficulties in accessing

services. A recent survey of 1,163 adults found that mental health concerns increased consistently

as the pandemic progressed.⁴⁶ From May 2020 to September 2020, depression symptoms increased

from 20.6 per cent to 59.2 per cent of respondents, and anxiety symptoms from 32.3 per cent to 55.1

per cent. Young people aged 18-29 were more vulnerable to mental health symptoms, but children

and adolescents were not included in the survey.⁴⁶

Other risk and protective factors identified from key informant interviews with stakeholders are

listed in Table 1.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Current responses to the mental health

needs of children and adolescents

Key national policies, strategies and legislation

An overview of key national-level policies and legislation relevant to mental health and MHPSS is set

forth in Table 2 with key documents summarized by sector.

TABLE 2. SUMMARY OF KEY MHPSS-RELATED LEGISLATION AND POLICY

Mental health

National mental

The National Mental Health Policy for

Psychiatric and Mental

health plan/policy/

Malaysia outlines advocacy, promotion,

Health Services Operational

strategy

prevention, treatment and rehabilitation.

policy 2011

It lays out eight guiding principles

National Strategic Plan for

for development in mental health -

Mental Health 2020-2025

comprehensiveness, accessibility

and equity, continuity and integration,

multisectoral collaboration, community

participation, human resource training,

standards and monitoring, as well as

research.

The National Strategic Plan for

Mental Health includes actions to

address mental health in children and

adolescents such as screening for early

detection and intervention, training of

students and teachers in psychological

first aid, and a continuous education

programme on mental health for

teachers.

Age of majority

18 years

Age of Majority Act 1971

Age of consent to

Based on this Age of Majority Act,

Age of Majority Act 1971

medical care

children below the age of 18 years are

Child Act 2001

deemed to be incapable to give consent

to medical treatment. The power to

give consent lies with their parents/

legal guardian. In special circumstances

(outlined in Section 21 of the Child

Act) a Protector or police officer may

authorize the treatment of a minor. It is

to be highlighted that this provision only

applies to a child referred to in section

21, i.e., a child who fulfils the definition

of ‘a child who is in need of care and

protection’ under section 17.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Standards of care

The National Adolescent Health Plan of

National Adolescent Health

for child/adolescent

Action aims to encourage and ensure

Plan of Action 2006-2020

mental health

the development of adolescents in

realizing their responsibilities for health

and empower them with appropriate

knowledge and assertive skills to enable

them to practice health behaviours

through active participation. The Plan

includes the strengthening of existing

mental health promotion programmes

targeted to adolescents in various

settings.

Protections within

According to the Mental Health Act,

Mental Health Act 2001

mental health

a guardian must give consent for a

legislation

minor’s admission to a psychiatric

hospital (Section 9) and must give

consent to a minor’s surgery (Section

77). In Section 2 of the Mental Health

Act, a ‘Guardian’ is defined as a person

who has lawful custody of the minor

(person under 18 years). There are no

special protections for minors.

Prohibition of

There is no national legislation on the

Guidelines on Management

physical restraint

use of restraints on children and young

of Aggressive Patients in

for those with acute

people. However, the use of physical

Ministry of Health Facilities

mental illness

restraints on children and adolescents

2016

is outlined in Section 9.1.1 of the

MoH Guidelines on Management of

Aggressive Patients in Ministry of

Health Facilities. The document states

that in restraining children, behavioural

approaches are preferrable; the Human

Rights Act 1998 and the UN CRC 1989

must be considered; restraint is NOT

allowed for children below the age of 12

years; and parents must be informed of

the management.

Right to mental

Unclear.

healthcare for those

deprived of liberty

Criminalization of

Whoever attempts to commit suicide

Penal Code of Malaysia

suicide

shall be punished with imprisonment for

1936

a term which may extend to one year or

with fine or with both (Section 309).

Whoever abets the suicide of a person

under 18 years of age shall be punished

with death or imprisonment for a term

which may extend to twenty years and

shall also be liable to fine (Section 305).

(Currently being revised.)

36 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Mental health and

No visions for child and adolescent

National Education

education

mental health or aspirations in

Blueprint 2013-2025

the National Education Blueprint

2013-2025.

Mental health and

No mention of child and adolescent

National Family Policy 2010

child protection

mental health (or mental health) in the

National Family Policy.

Protection

Rights of children

Malaysia became a party by accession

Child Act 2001, Sexual

and adolescents

to the Convention on the Rights of the

Offences Against Children,

Child on 17 February 1995.

Act 2017 [Act 792],

Domestic Violence Act 1994

Malaysia enacted the Child Act 2001

and The Convention on the

to ensure that children will be provided

Rights of the Child

with necessary care, protection, and

intervention, especially those children

deprived of a family environment.

Age of sexual

16 years.

Penal Code of Malaysia

consent

1936 (Section 375)

Exception: sexual intercourse by a man

with his own wife by marriage is not

rape.

Refers only to a man committing rape

if he has sexual intercourse with a

woman under 16 years of age (with or

without her consent). Does not make

the age of sexual consent for boys or

the age of sexual consent for same-sex

couples clear.

Age of marriage

Non-Muslims:

Law Reform (Marriage

and Divorce) Act 1976,

18 years with parental consent. But

(Sections 3, 10, 12); Islamic

16 years for girls if solemnization of

Family Law (Federal

marriage is authorized by a licence

Territories) Act 1984,

granted by the Chief Minister.

(Section 8); Undang-undang

Muslims in the Federal Territories:

Adat

Boy: 18 years; Girl: 16 years. But

younger if permission is granted by a

Syariah Judge.

Sabah and Sarawak population:

According to the customary law

(Undang-undang Adat) of each ethnic

group.

Orang Asli (aborigines) population:

No age limit is provided under any

written law. It is at the discretion of the

Community Chief (Tok Batn).

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Prohibition of

Section 31 of the Child Act 2001 states

Child Act 2001

violence

that any person who, being a person

having the care of a child abuses,

neglects, abandons or exposes the child

or acts negligently in a manner likely

to cause them physical or emotional

injury or causes or permits them to be

so abused, neglected, abandoned or

exposed or sexually abuses the child

or causes or permits them to be so

abused, commits an offence.

Laws on corporal

Corporal punishment is lawful in the

Penal Code of Malaysia

punishment

home under Sections 89 and 350 of

1936

the Penal Code. Corporal punishment

Education Act 1996

of boys is lawful in schools, regulated

by the Education Regulations (Student

Discipline) 2006, under the Education

Act 1996. Corporal punishment is lawful

as a sentence for crime.

Prohibition of

No conscription. The minimum age for

recruitment into the

voluntary recruitment is 17 years.

armed forces

The constitution states that all forms

of forced labour are prohibited, but

Parliament may by law provide for

compulsory service for national

purposes (Section 6).

Minimum age

10 years (or a child above 10 and under

Penal Code of Malaysia

of criminal

12 years of age, who has not attained

1936

responsibility

sufficient maturity of understanding) -

Chapter 4 (General Exceptions) of the

Penal Code.

Age of child labour

15 years.

Children and Young Persons

(Employment) Act 1966

Laws to protect children under 17

(Amendment 2010)

years. Exceptions can apply for work

in a family business or other jobs

authorised by the government.

Criminalization

Same-sex sexual acts between men

Penal Code of Malaysia

of same-sex

criminalized (Section 377A).

1936

consensual sex

Protection for youth

Unclear.

and families

38 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Health sector

Malaysia’s key mental health laws are the Mental Health Act 2001 and Mental Health Legislation

2010.⁴⁷

The Act provides a framework for the delivery of treatment and rehabilitation of those with mental

disorders; licencing and monitoring of facilities; and the rights and protections of persons within the

mental health system. While the Act defines the role of a guardian in providing consent for ‘minors’,

it does not define special protections for children or adolescents under the age of 18 years.

The Act is supported by the Psychiatric and Mental Health Services Operational policy 2011.²³ This

policy identifies the mental health of children and adolescents as a priority and defines general

principles for the provision of care for this age group, including assessment and treatment through

a multidisciplinary team; evidence-based and multimodal care; provision of services outside

traditional hospitals or clinic settings (and the need to avoid admitting children to adult facilities);

referral mechanisms; and the role of psychiatrists in reporting suspected child abuse and neglect.

The policy also emphasizes the need for collaboration outside the health sector to support screening

and referral and the importance of mental health promotion (including in schools), although it lacks

specific details about actions or implementation. The policy additionally notes the current lack of

specialist and multidisciplinary teams for child and adolescent mental health. It recognizes the rights

of children and adolescents to confidential care and the need for their assent in addition to the assent

of guardians. Nevertheless, there is no detailed guidance concerning the rights of adolescents to

access care independently.

The National Mental Health Policy was formulated in 1998 and revised in 2012. Additionally, the Mental

Health Framework was developed in 2001.⁴⁷ The National Mental Health Promotion Advisory Council

was established in 2011 and includes the Minister of Health and representatives from government

and non-government agencies.⁴⁷ There is no separate plan or strategy for child and adolescent mental

health.¹⁵ Of the aforementioned policies and laws, child and adolescent mental health is most explicitly

targeted in the Mental Health Framework, which focuses on improving care for target groups.⁴⁷ The

National Strategic Plan for Mental Health 2020-2025⁴⁸ outlines eight strategies that span the tiers

of responsive care, prevention and promotion. Actions to address mental health in children and

adolescents include screening for early detection and intervention, training of students and teachers

in psychological first aid, and continuous education programmes on mental health for teachers.

Stakeholders noted that several actions from the strategic plan, such as decriminalization of suicide

and the prevention/promotion programme ‘Let’s Talk Minda Sihat’, are currently under way. The

implementation of other actions remains unclear.

The Malaysian Government has also developed policies to specifically improve adolescent health,

including mental health. In 1995, the Ministry of Health established the Adolescent Health Unit within

the Family Health Development Division.¹⁴ Primary adolescent health clinics have made healthcare,

including mental healthcare, more accessible and approachable for young people (see next section).

The National Adolescent Health Policy and National Adolescent Health Plan of Action 2006-2020

includes mental health as one of five priority areas for adolescent health. While it encompasses

broad, cross-cutting actions that are needed to support health promotion and access to services, it

does not, however, include specific actions for mental health.⁴¹

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Education sector

The focus of the National Education Blueprint 2013-2025 is on ensuring quality education and academic

outcomes as well as equity of access. However, it also emphasizes a commitment to the holistic

development of children and adolescents, including emotional development. While the Blueprint

does not specifically address mental health, it stresses the importance of school environments

and a curriculum that supports resilience, emotional intelligence, positive peer relationships and

communication skills for all ages. It also defines the response of the sector to support the learning

needs of children living with disability.

Social welfare sector

There is a suite of policy and legislation addressing the social determinants of mental health for

children and young people in Malaysia. The Child Act of 2001, last amended in 2016, is the key

legislation protecting the rights of children and adolescents who have been abused, neglected or

abandoned.⁴¹ The Act requires medical assessment, examination and access to treatment (including

psychiatric care) and protections for children who are suspected of being a victim of ill-treatment,

neglect or abuse. The welfare and rights of children are also protected under the Sexual Offences

Against Children Act 2017, the Evidence of Child Witness Act 2007, the Domestic Violence Act 1994,

the Guardianship of Infant Act 1961, the Married Women and Children Maintenance Act 1950, the

Adoption Act 1952, the Registration of Adoptions Act 1957 and the Anti-Trafficking in Persons and

Anti-Smuggling of Migrants Act 2007.⁴¹ While these do not specifically address mental health needs,

these Acts provide a strong framework for the protection of child rights and the provision of a safe

and enabling environment for children to thrive.

The National Policy for Children and the National Child Protection Policy also guarentee the rights of

all children, including those with disabilities, to be protected from all forms of neglect, abuse, violence

and exploitation. The main objectives of the Policy include increasing awareness and commitment to

child protection, creating safe and child-friendly environments, encouraging organizations to develop

child protection policies, protecting children from all forms of violence, enhancing support services

to address neglect, abuse, violence and exploitation, and enhancing research and development.

Other national plans which may improve conditions and safety for children and young people include

the National Action Plan on Trafficking in Persons 2021-2025, the National Policy for Persons with

Disabilities 2007, the Malaysia Plan of Action for Persons with Disabilities 2016-2022 and the National

Family Policy 2010.⁴¹

Justice sector

The Child Act 2001 provides some safeguards for children who need care and protection. It includes

requirements for medical assessment, examination, access to treatment (including psychiatric care)

and protections for children who are suspected of being a victim of ill-treatment, neglect or abuse.

For children in conflict with the law, the Child Act 2001 is silent on the requirements for medical

assessment, examination and access to treatment. The Ministry of Health Guideline on Medical

Assessment of Child Custody Cases 2018 requires the assessment of emotional and psychological

needs, and defines the referral process for children undergoing custody disputes.⁴⁹

40 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Current programmes and approaches to

address child and adolescent mental health

and psychosocial well-being

Responsive care for children and adolescents with mental health

conditions

 Screening and early

identification of needs

for those at risk of poor

Clinical

mental health, and

care

referral pathways for

Sub-clinical

services and supports

care

 Management of clinical

and sub-clinical mental

Targeted

health conditions

prevention

 Continuing care and

support for children and

Universal

adolescents with mental

prevention

health needs

Ensuring an enabling

and safe environment

The mental health system in Malaysia is coordinated and regulated nationally by the Ministry of

Health. The Ministry’s Medical Programme is responsible for hospital psychiatric services and the

Public Health Programme is responsible for mental health in primary care.⁵⁰ The Ministry of Education

and Ministry of Defence also have roles in responsive care by directly providing services in teaching

and army hospitals. Currently, responsive care is primarily provided through the health sector, through

clincial mental health services.

Screening and early identification of mental health needs

There is limited information about the national approach to early identification and screening of

children and adolescents for mental health conditions. Psychological risk assessment of adolescents

is integrated into adolescent-friendly health services. This assessment is carried out by trained health

staff using the Health Status Screening Form developed by the Ministry of Health.⁴⁷ At primary

healthcare facilities, there is also a programme called ‘Healthy Mind’, which screens for mental

health using the internationally validated, 21-item Depression, Anxiety and Stress Scale (DASS-21).⁴⁷

Since 2011, the Ministry of Health and Ministry of Education have collaborated to implement the

‘Healthy Mind’ mental health screening programme among 16-year-olds in schools. Students are

asked to self-report using the DASS-21²² and are referred to services as appropriate. More than 2,300

counsellors have been trained to deliver this screening programme in schools.⁴⁷ In 2015, 55.9 per

cent of all students in Malaysia had been screened through this programme.²² On average, 3.6 per

cent of students were found to have severe depression.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Stakeholders from across sectors noted a lack of early identification and screening, particularly in

non-health settings. Young people themselves identified schools as a potentially important setting

to provide screening of students with behavioural problems or other signs of poor mental health.

Referral pathways

A 2019 study of over 2,000 referrals to psychologists across seven government hospitals found that

25.7 per cent of referrals were for children and 22.8 per cent were for adolescents.⁵¹ The majority

of referrals were for neurodevelopmental disorders, followed by depressive disorders, obsessive-

compulsive-related disorders, and anxiety disorders.⁵¹ Stakeholders acknowledged that within the

health sector, there is a formal referral pathway for step-up and step-down care. Practitioners from

primary care can refer cases to clinical psychologists or psychiatrists at the hospital for specialized

care. Similarly, practitioners from tertiary care can refer back stable cases to primary care for care in

the community. One drawback in the mechanism is that the communication happens via a physical

referral letter which is the responsibility of the patients/caregivers to transport between the referring

party to the referred party. Should the patients/caregivers decide not to abide by the referral, there

is no mechanism in place for tracing this loss to follow-up.

Referral between sectors is most commonly communicated through referral letters provided to

parents/caregivers. For example, a school counsellor can write to a psychiatrist at the specialist clinic

for further care. The onus is then on the parents/caregivers to bring their child to the specialist clinic to

secure an appointment. In some settings, children and their families may be physically accompanied

to a specialist by a counsellor or social welfare officer. For cases needing urgent specialized care, the

first point of contact with the health sector may be through the primary care clinics or directly with

the tertiary care facilities via the emergency department.

Although there are no obstacles in referring, stakeholders observed that the process is usually

one-way. After referring, the initial provider is not updated on the progress or management unless

they hear back from the child or family themselves, creating challenges to providing follow-up and

continuing care and support.

“For me, if we were to put it on a scale, we are now possibly at a scale of 6 on cooperation

between sectors. We can cooperate because we can call for help, but how far the thing

progresses, we don’t know the development…after referring, we don’t know what happens

unless the client comes back to us and we ask for their feedback..” —A social welfare sector

informant

Limited availabilty of specialist services is a key challenge for referral pathways. Stakeholders noted

the long waiting time to get an appointment at specialist clinics, contributing to treatment delays

and/or parents/caregivers not seeking further care.

“…so far it is difficult to get appointment dates…when they have to wait for a long time,

usually they will be fed up and end up not going to the appointment. Perhaps there’s something

there...perhaps the linkage (referral) can be further improved.” —A social welfare sector

informant

Management of mental health conditions and continuing care

Over the last 20 years, the Malaysian Ministry of Health has engaged in substantial reform of mental

health services, including for children and adolescents. Prior to 2001, mental health services focused

on inpatient management, which was managed separately from primary care. The 2001 National Mental

Health Policy guided the integration of mental health into primary healthcare.¹⁷ Currently, 89 per cent

of all primary health clinics provide mental health services,⁴⁷ which include initial screening, diagnosis,

treatment and rehabilitation. Approximately 25 per cent of primary health clinics also have family

medicine specialists, who have additional (but limited) psychiatry training.²² Complex cases may be

referred to specialized outpatient clinics. Across Malaysia, there are 28 specialized psychiatry outpatient

clinics specifically for children and adolescents, including for developmental disorders. Almost every

state has at least one specialized outpatient service.¹⁵ In 2015, there were a total of 38,956 child and

42 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

adolescent psychiatric clinic visits across the country. ²² In 2017, there were 83.5 child and adolescent

psychiatry clinic visits per 100,000 population. ¹⁵ A technical report in Malaysia in 2015 found that 99.1

per cent of patients waited six weeks or less for a first specialist psychiatry consultation. ²²

Malaysia has approximately 49 general public hospitals with inpatient psychiatric units,⁵⁰ 38 of which

can admit children and adolescents,¹⁵ as well as four large mental health hospitals.⁵⁰ Out of 5,367

inpatient psychiatric beds across the country, 4,240 (79.0 per cent) are in the four main psychiatric

hospitals.⁵⁰ For both inpatient and outpatient care, most services for children and adolescents are

provided by general psychiatrists - there were fewer than 10 child psychiatrists in Malaysia as of

2015.¹⁶ In 2017, there were 14.99 mental health-related hospital admissions per 100,000 population

in Malaysia. For children and adolescents, the mental health hospital admission rate was 13.86 per

100,000.¹⁵ In a 2011 report, 37 hospitals offered community and psychosocial rehabilitation services,⁵⁰

although data for children and adolescents were not available.

The Ministry of Health has implemented specific adolescent health services since 1995. These are

primary care services aimed at adolescents to promote healthy lifestyles and holistic well-being,⁵²

and are available at mainstream health clinics and through school health units.⁵³ In 2018, the Ministry

of Health introduced national best practices for adolescent-friendly health services.^53,54 In order

to be accredited as adolescent-friendly, clinics are now assessed in terms of compliance with 12

criteria, including appealing ambience for adolescents, confidentiality of processes, integration of

all services under one roof, adolescent engagement in service assessment, and training of staff in

psychological risk assessment on adolescents using the HEADSS framework.^53,54 HEADSS is an

adolescent psychosocial assessment that covers the domains of home, education and employment,

activities and peer relationships, drug use, sexuality and gender, and suicide or self-harm. A study

in the state of Kelantan found that 35 per cent of its 85 health clinics had qualified as adolescent

friendly. Adolescent-friendly clinics scored significantly higher than conventional clinics in 11 out of

12 criteria for best practices.⁵³ In a survey, adolescents attending adolescent-friendly clinics showed

significantly higher satisfaction levels compared with their peers attending conventional clinics.^53,54

However, service quality with respect to mental health was not specifically assessed.

Other sectors are also involved in supporting person-centred and continuing care. Children with

disabilities are registered with the Department of Social Welfare on a voluntary basis. Since 2001

the Ministry of Education has been responsible for special education programmes for children

with learning disorders.¹⁶ There are also some examples of smaller programmes piloted in schools.

In Pahang state, a school-based cognitive behavioural therapy (CBT) intervention known as Shine

Through Any Roadblocks (STAR) was piloted.⁵⁵ Eighty-five adolescents from eight secondary schools

were recruited and assigned either to an intervention group or control group. Participants showed

higher depressive scores than average but did not have a psychiatric diagnosis. The intervention

consisted of eight, 1-hour group sessions over two months and involved small-group seminars,

hands-on activities, interactive discussions and homework to provide education on CBT principles,

managing thoughts, feelings and behaviours, and improving relationships and communication skills.

The intervention group was found to have significant and sustained, reduced levels of depressive

symptoms and automatic negative thoughts compared to the intervention group.⁵⁵

Private sector engagement in the delivery of mental healthcare has been limited, owing partly to the

restrictions under the previous mental health legislation, and has taken the form of private nursing

facilities and private specialty services. Numerous NGOs play a part in providing MHPSS, including

the Malaysian Mental Health Association, the Malaysian Psychiatric Association, and the Mental

Illness Awareness and Support Association, among others.

There has been a significant increase in the availability of online or digital mental health services.

For example, the Befrienders and Talian Kasih 15999 helplines provide emotional support and

counselling countrywide. During the COVID-19 crisis in 2020, UNICEF partnered with the Malaysian

Government to deliver innovative psychosocial support services, including online and telephone

helplines to address mental health issues, suicide and domestic violence.⁵⁶ UNICEF and the National

Early Childhood Intervention Council delivered telehealth psychosocial support for over 450 children

with disabilities and over 450 parents.⁵⁶ UNICEF also partnered with the Ministry of Education

and local NGOs to build the capacity of school counsellors to deliver psychosocial support.⁵⁶ Other

examples of digital services include:

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Guidance for social workers and social service practitioners Ten ideas for social workers and

social service practitioners on how to undertake remote case management in order to safeguard

children when face-to-face contact with them and their families is restricted due to COVID-19

containment measures.

WeConnect (KitaConnect) UNICEF Malaysia established WeConnect (KitaConnect) in March

2020 to listen to and answer young people’s concerns about MHPSS. The network comprises

social media influencers and mental health specialists who raise awareness about mental health

and provide practical advice to young people. In 2020 UNICEF reported the engagement of over

270,000 young people with this programme.⁵⁶

Additionally, there are private helplines and online services that cater to children and adolescents,

including:

Buddy Bear Helpline The Buddy Bear helpline is a telephone service established by social enterprise

HumanKind to assist disadvantaged populations with mental health difficulties, particularly children

who wish to express their fears and concerns about the COVID-19 pandemic

Befrienders Kuala Lumpur Befrienders is one of the main mental health support hotlines in Malaysia

that offers emotional support to people who are distressed, despairing or struggling with suicidal

thoughts. Every conversation is treated in strict confidentiality to encourage people to openly

share without fear. Callers can also schedule an appointment for a face-to-face consultation.

A range of barriers nevertheless prevents children and adolescents from accessing quality mental

health services. A 2010 study among 175 secondary school students found that none reported

using primary health services for mental health problems.⁵² The most common reason was a lack of

awareness about the availability of mental healthcare in primary health clinics. More than half (55.4

per cent) thought their mental health issues were due to their own mistakes, 43.2 per cent were

worried about confidentiality if they sought help, and 48.6 per cent were concerned about stigma

from family and friends.⁵² Despite government efforts in recent years, access is still a major barrier

to mental healthcare, especially for the most vulnerable. A 2015 study in Penang surveyed families

of children with disabilities, including learning, visual, hearing, physical or multiple disabilities. A

quarter of children were in need of psychology services, among whom 63.0 per cent of needs were

unmet.⁵⁷ Common reasons for unmet needs included: the place of service was too far, there was

no-one to take the child for therapy, the unaffordability of therapy, and insufficient time to attend

therapy.⁵⁷ People with a mental disorder and their families frequently seek traditional faith healers

before consulting conventional medical staff.^58,59 A 2011 study among hospitalized patients with first

episode psychosis found that 32 per cent had three or more non-psychiatric contacts before hospital

admission. Almost half (48 per cent) of these individuals had sought help from traditional healers

before seeking a psychiatric service.⁵⁰

Stigma and low mental health literacy were also noted by stakeholders as key barriers impacting on

access to mental health services.

“I think a lot of people don’t understand and a lot of people actually don’t believe children

have mental health problems. They will say that why is it that children have mental health

problems? It’s not like they have stress” —A social welfare sector informant

“The parents, they are not able to accept mental health (issues) as a problem. They think that

is not a problem and they think it’s something that is normal. You just go through, everybody

goes through. So, there’s lack of knowledge and therefore lack of support for the children”

—A social welfare sector informant

“Because what I see is when it comes to mental health, people are more comfortable talking

to a non-profit organization than trained professions, because they don’t want to talk and

say that ‘I have mental illness’. It’s still the stigma associated with ‘I have a mental health

problem’”. —A social welfare sector informant

44 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Prevention of mental health conditions in the immediate social

context

 Building individual

Clinical

care

assets

 Strengthening positive

Sub-clinical

peer support (including

care

digital media)

 Psychosocial

Targeted

competence building for

prevention

parents / carers

 Safe and enabling

Universal

learning environment

prevention

Ensuring an enabling

and safe environment

Actions to prevent poor mental health by addressing risk factors and enhancing protective factors

are critical to ensuring mental health and well-being. For children and adolescents, this requires a

focus on factors related to where they live, grow, learn and socialize, with parents/carers, peers and

learning environments a high priority. The health, education, justice and social welfare sectors, along

with NGOs and youth organizations, all play key roles in supporting current mental health prevention

programmes targeting the general population, school children and teachers, parents and at-risk

children and adolescents.

Building individual assets

At present, activities to promote the mental health and well-being specifically of children and

adolescents are aimed at: (i) equipping students with appropriate knowledge, attitude and skills

about mental well-being through: (a) an infotainment approach (animation characters, e.g., Upin

& Ipin, Didi & Friends) at pre-school, (b) an infotainment approach, games and contests at primary

school, and (c) an e-mental health approach (social media, internet, apps) at secondary school;

and (ii) empowering students toward positive mental well-being and to seek help when needed

through training in emotional regulation, communication and social skills, such as the peer counsellor

(Pembimbing Rakan Sebaya) programme

There are also some examples of smaller-scale or pilot programmes to build individual assets and

support social and emotional learning. From 2017 to 2018 in Jerantut, Pahang, an anxiety prevention

programme for primary school students was trialled, based on stimulus response theory and an

information-motivation-behavioural skills model.⁶⁰ A cluster, randomized controlled trial was conducted,

whereby 193 children in five schools received the intervention and 268 children in six schools received

no intervention. Both groups completed questionnaires before, immediately after, and three months

post intervention. However, the impact of the intervention was very small on the primary measure

of anxiety, and there were no changes in regard to the secondary measures of worry, coping skills

and self-esteem.⁶⁰

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

From 2014 to 2015 in Klang Valley, Selangor, a Life Skills Education programme was implemented

based on WHO guidance in a randomized controlled trial at eight orphanages. The trial recruited

287 adolescents aged 12-18 with mild depression, anxiety or stress.⁶¹ The intervention group was

associated with a significant increase in positive, problem-based coping skills such as using emotional

support and positive reinterpretation, and a significant decrease in dysfunctional coping skills like

substance abuse and self-blame, compared to the placebo programme group. However, the study

could not establish a causal relationship between an improvement in coping mechanisms with

decreased levels of depression, anxiety or stress.

Strengthening positive peer support

Despite the importance of promoting healthy peer relationships, addressing bullying and violence

and supporting positive peer networks, few examples of programmes to strengthen peer support

were identified. There were limited community activities for children and adolescents; hence, the

stakeholders identified this area as a key priority.

On a small scale, a quasi-experimental study was conducted in 2010 to assess the efficacy of the

Olweus Bullying Prevention Programme in Malaysia.⁶² Almost 4,000 participants were recruited from

three intervention schools and three control schools. In the intervention schools, programmes included

formation of an anti-bullying committee, defining and enforcing rules within classrooms, discussions

and activities to reinforce positive behaviour. Coordination with school counsellors and parents to

monitor for bullying outside classroom settings were included as part of the programme. After one

year, two of the three intervention schools showed significant reductions in bullying and victimization

compared to the baseline, while no school in the control group showed any improvement.⁶²

Psychosocial competence building for parents/carers

In Malaysia, Positive Parenting, a multifaceted parent education programme that emphasizes family

wellness was set up in 2000. Positive Parenting was developed and implemented by healthcare

professionals from various professional bodies, including the Malaysian Psychiatric Association,

Malaysian Society of Clinical Psychology (MSCP), Malaysian Mental Health Association (MMHA),

National Population and Family Development Board Malaysia (LPPKN), Nutrition Society of Malaysia

(NSM), Obstetrical & Gynaecological Society of Malaysia (OGSM), Malaysian Association of

Kindergartens (PTM), and Association of Registered Childcare Providers Malaysia (PPBM). Although

Positive Parenting has since grown and successfully evolved in a unique way to reach out to modern-

day parents with useful information on parenting through various channels, feedback from stakeholders

suggested the need to intensify the dissemination of this programme, especially in rural areas.

UNICEF Malaysia, in partnership with the National Family Development Board, Parenting for Lifelong

Health and University Putra Malaysia, also developed evidence-based parenting tips in an initiative,

launched in in May 2020, to help parents and caregivers cope during the COVID-19 pandemic and the

lockdowns. The parenting tips, covering the topics of violence prevention, self-care and psychosocial

well-being, were disseminated through UNICEF’s social media platforms and have since reached

more than 1.2 million social media users.

A number of pilot studies or trials of parenting programmes have been conducted, aimed at families at

risk. In 2020, a randomized controlled trial was launched of a supportive parenting intervention among

Afghan and Rohingya refugees in Malaysia, in the context of the particular uncertainties and stress

these groups face. Seventy-nine mothers were recruited through community centres and networks⁶³

and they were randomized to an intervention group and a control group, with a three-month follow-up

assessment conducted with both groups. The intervention involved one-hour sessions weekly for

eight weeks and included check-ins, small-group seminars, group discussion and role plays on topics

such as improving health and emotional well-being, adjusting to a new environment, strengthening

family relationships and managing child behaviour. On evaluation, the intervention group had more

beneficial outcomes on several measures, including child intensity (challenging behaviours), parenting

self-efficacy (confidence they can manage their child’s behaviours), family intimacy, family conflict,

and parental emotional distress, compared to the control group. However, there were no differences

between the intervention and control groups on measures of positive parenting (reinforcing good

behaviour), inconsistent discipline or poor supervision.

46 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Safe and enabling learning environments

The National Education Blueprint emphasizes the importance of school environments and a curriculum

that supports resilience, emotional intelligence, positive peer relationships and communication skills.

However, there are no documented examples of whole-of-school or whole-of-education mental

health promotion approaches in Malaysia. In 1963, the Education Planning and Research Division of

the Malaysian Ministry of Education established a guiding and counselling section. There is now at

least one full-time counsellor in every secondary school in Malaysia.⁶⁴ The role of counsellors often

involves both traditional activities such as counselling, career guidance and education as well as

rule-enforcement roles such as the checking of badges or instituting disciplinary action for tardiness

or other infringements.^64,65 Studies have found that school counselling services are unpopular with

students in Malaysia, partly due to fears of being stigmatized for using them.⁶⁴ However, there are

few data formally evaluating the effectiveness of school counselling in Malaysia. A 2017 qualitative

study in Perak State found that counsellors struggled with a very wide job description, insufficient

opportunities for engagement with other stakeholders and schoolteachers, and a need for a much

more collaborative approach to manage these issues.⁶⁴ Other than the anti-bullying pilot described

above, there were no documented national programmes to address violence or harassment in schools

or other education settings.

Targeted interventions for children and adolescents at higher risk

There are several programmes aimed at children and adolescents who are at increased risk for poor

mental health due to risk behaviours or high-risk exposures - in particular programmes to prevent

and respond to child abuse, violence, exploitation and neglect.

The Department of Social Welfare (DSW) Children’s Division has responsibility for the administration

of child protection and child justice. The DSW’s responsibilities include support for neglected and

abandoned children, investigating child abuse cases, implementing the National Strategy Plan in

addressing the causes of child marriage, and providing protection, rehabilitation and interventions in

regard to children who are involved in illegal sexual activities.^41,66 Child Protectors work in each state

to coordinate prevention and response to child protection concerns. Within the DSW, the approach

to child protection includes primary services (focused on raising awareness of child rights and child

abuse), secondary-level services (hotlines, community care centres, crisis centres and family centres

to support those at risk), and tertiary-level services (care homes, emergency services, crisis centres,

and suspected child abuse and neglect teams in hospitals and police units).⁶⁷

The DSW runs a network of nine ‘Rumah Tunas Harapan’ (temporary shelters) for children under

protection or not living with their biological family and 15 children’s homes with a capacity for 1,480

children.⁶⁸ The DSW also runs facilities for the protection and psychosocial support of children who have

been exposed to forced labour, slavery trafficking or sexual exploitation.⁶⁹ For children in the juvenile

justice system, the DSW also has community-based and institutional rehabilitation programmes.⁶⁸

The DSW has a ‘Counselling and Psychology’ division that provides some psychosocial services

for children in protection and rehabilitation. Specific programmes include counselling for victims

of trafficking or forced labour, counselling for children with identified psychosocial and emotional

issues, and even interactive workshops for families with problematic dynamics.^66,69 A UNICEF report

found that inter-agency collaboration between hospital teams and DSW on suspected child abuse

and neglect cases was particularly strong in Malaysia. It was reported that child victims of serious

violence had access to comprehensive and child-sensitive psychosocial, legal and medical services.⁴¹

There are also some non-government programmes to support children who experience violence or

neglect and that address risk factors for mental health:

Protect and Save the Children Protect and Save the Children encourages children experiencing

sexual abuse and exploitation to speak up, be heard, and receive help. To build safer communities

and protect children’s rights, it organizes frequent educational programmes, campaigns, forums and

conferences for the general public. Importantly, the programme provides prevention, intervention

and treatment services for children and families suffering from sexual abuse. Moreover, it fosters

an environment of trust whereby children can freely speak about their experiences without fear

of judgement or punishment.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

Women’s Aid Organization Since 1982, Women’s Aid Organization has been providing free crisis

support and shelter to women and children facing domestic violence. In 2014, the organization

started its WhatsApp hotline TINA, which stands for ‘Think I Need Aid’. Currently, it offers

confidential services to survivors of domestic violence, sexual abuse, rape and other forms

of violence. Women’s Aid Organization also provides face-to-face consultations and access to

services like shelter and social work.

The DSW also implements substance abuse prevention programmes, such as the PINTAR programme

providing education to primary school students aged 10-12, and the SHIELDS programme for at-risk

adolescents aged 13-18.⁶⁸

Ensuring a safe and enabling environment to promote mental

health

 Policy and legislation for

child and adolescent

Clinical

care

mental health, and to

protect children and

Sub-clinical

adolescents from harm

care

and discrimination

 Community

Targeted

engagement and

prevention

participation to promote

mental health and

Universal

address harmful norms

prevention

Ensuring an enabling

and safe environment

In addition to key policies and legislation for MHPSS and to protect children from harm (described

above), promotion of awareness about mental health has been a key stated goal in Malaysian mental

health plans.⁴⁷ Since 2000, the Government has launched multiple activities for mental health

promotion in the community, including World Mental Health Day commemorations and anti-stigma

campaigns such as ‘Stop Exclusion: Dare to Care’.⁴⁷ Multiple nationwide suicide prevention campaigns

have also been implemented, including talks, media coverage, exhibitions and seminars. Since 2003,

the Ministry of Health’s national ’Healthy Lifestyle’ campaign has incorporated messages on ‘handling

stress effectively’ and ‘enhancing a healthy mind’.⁴⁷

Mental health promotion in the general community has grown over the last two decades in Malaysia.

Several NGOs have helped to increase awareness of mental health and advocate for improved services,

such as the Malaysian Mental Health Association,^16,17 Malaysian Psychiatric Association, Mental Illness

Awareness and Support Association, and the Psychiatric Welfare Body.⁵⁰ These NGOs collaborate via a

government body known as the Malaysian Mental Health Council.⁴⁷ There are also some subnational

programmes to improve mental health literacy among communities with a higher burden of poor mental

health. For example, Sabah had the highest prevalence of mental health conditions among adults

in the 2015 NHMS, particularly among indigenous populations. In response, the Ministry of Health

and Universiti Malaysia Sabah implemented a comprehensive programme to improve mental health

literacy.⁷⁰ The intervention utilized various strategies and modalities to promote mental health literacy

48 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

in schools among children and adolescents. The Ministry of Health and Universiti Malaysia Sabah have

also collaborated with the Kadazandusun Cultural Association to reach traditional healers, indigenous

chiefs and village elders and with rural village associations and volunteers to engage rural indigenous

populations. Another intervention involved engaging social media celebrities to reach social media users

and using mental health promotional videos in native languages.⁷⁰

Other approaches to improve mental health literacy and well-being in the general population include:

Implementation nationwide of the ‘Let’s TALK Minda Sihat’ campaign and Malaysia Mental Health

Film Festival;

Empowerment of NGOs and relevant community groups on mental health promotion, enhancing

awareness and early detection and intervention in the community via (a) training of trainers (and

echo training) for NGOs and the community, and (b) conducting campaigns and community

dialogues particularly aimed at engagement with religious groups;

Equipping and enabling workers with the appropriate knowledge, attitude and skills on mental

well-being via (a) training on mental health and work life balance (e.g., Stress Management

at Workplace Programme, DOSH Stress at Workplace guideline), (b) involvement in ‘Healthy

Communities, Building the Nation-Plus’ (KOSPEN Plus) programme, and (c) promotion and

advocacy of mental health to employers.

Mental health and psychosocial well-being:

The current situation for children and adolescents in East Asia and the Pacific

The package of priority MHPSS actions was defined during the development of the regional conceptual

framework in the initial phase of this project. As described previously, these actions were identified

through a review of existing frameworks, guidance, evidence and expert consensus. As part of the

application of the regional conceptual framework to national contexts, this package was reviewed,

refined and prioritized in Malaysia during consultation workshops and through an online prioritization tool

and key informant interviews. The final package of actions prioritized for Malaysia is set forth in Table 3.

Table 3. Package of priority MHPSS actions for children and adolescents

Accessible and responsive care for mental health conditions

Screening and early identification of needs

DOMAIN

ACTION

Early identification

Train and sensitize social service workforce, justice sector workers,

of mental health

teachers and other education staff and school-based counsellors to

conditions and risks

identify, support and refer children and adolescents with mental health

needs.

Train and sensitize frontline and community-based health workers to

identify, support and refer children and adolescents with mental health

needs.

Screening of

Strengthen screening of children and adolescents with high-risk

children and

behaviours (e.g., substance use) in clinical, school, child protection and

adolescents at

justice settings.

higher risk for poor

Strengthen screening of children and adolescents with high-risk

mental health

exposures (e.g., family violence) in clinical, school, child protection and

justice settings.

Strengthen screening of pregnant and postpartum adolescent girls

through antenatal and postnatal services.

Strong referral

Establish referral criteria and mechanisms both within the health

pathways

system and from other sectors/settings (schools, social welfare/child

protection and justice).

Strengthen self-referral through helplines/hotlines/online.

Integrate mental health into primary healthcare and physical health

services.

Management of clinical and subclinical mental health conditions

DOMAIN

ACTION

Accessible and

Establish child, adolescent and family friendly services that are

inclusive mental

inclusive.

health services

Deliver community-based, online and mobile services for underserved

children and adolescents.

Responsive care

Establish child and adolescent specialist support, case management

for subclinical

and therapy provided by multidisciplinary team.

conditions

Establish specialized services and support to families of children with

complex behaviours and needs in social welfare/child protection/justice

settings.

Introduction

Responsive care for Establish specialist clinical child and adolescent mental health

mental disorders

treatment and care (including hospital-based care.)

Provide child and adolescent mental health residential rehabilitation

services.

Continuing care

DOMAIN

ACTION

Continuing care for

Provide person-centred care that includes social support, peer support

those with mental

and mental health professionals to support recovery and rehabilitation.

health conditions

Ensure ongoing participation in education for those with mental health

conditions.

Provide education and support for parents of children and adolescents

with mental health conditions.

Prevention of mental health conditions in the immediate social context

Build individual assets of children and adolescents

DOMAIN

ACTION

Social and

Implement universal interventions and approaches in schools and out-

emotional learning,

of-school settings that focus on: social and emotional learning; positive

resilience and

behaviours; social connectedness; effective problem-solving; help-

problem-solving

seeking behaviour; and common risk factors for poor mental health.

skills

Targeted

Deliver selective, intensive programmes in clinical, school, community,

interventions

residential care and justice settings for children and adolescents

for children and

with high-risk behaviours (such as substance use) or exposures

adolescents at risk

(including as part of emergency response in humanitarian or disaster

settings). Can be packaged with counselling and referral to services for

screening and further care.

Provide guidance and support to schools on effective interventions

following a crisis (including suicide in the community.)

Build the psychosocial competence of parents and carers

DOMAIN

ACTION

Safe, stable

Implement programmes to raise awareness about nurturing care,

parenting and

positive parenting and non-violent discipline.

attachment

Scale-up parenting programmes focused on building skills in nurturing

and responsive care, positive parenting practices and non-violent

discipline.

Identify and address mental health needs of parents/guardians/carers.

Strengthen positive peer support, including online

DOMAIN

ACTION

Positive peer

Establish and support peer-to-peer groups and youth clubs in school

relationships

and community settings, and youth counsellor programmes.

Develop or strengthen online social networks that promote mental

health literacy and positive peer support among children and

adolescents.

52 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Address peer

Implement programmes to promote online and digital civility and

victimization

digital literacy among children, adolescents, parents and teachers.

Integrate education on digital civility and literacy into the school

curriculum.

Implement school policies and curricula that promote healthy and

respectful peer relationships and address peer-to-peer violence and

harassment.

Ensure safe and enabling learning environments

DOMAIN

ACTION

Optimal school

Implement a whole-of-education approach to mental health promotion

environment for

(early education, primary and secondary levels). In addition to

mental health and

curriculum-based and other approaches to support social and emotional

well-being

learning and positive peer relationships outlined above, this should

also include strategies and policies to ensure a safe, respectful and

inclusive environment with a focus on well-being; a positive approach to

behaviour management and violence prevention; and participation and

partnerships with students, parents, community and service providers.

Promote teacher-parent communication on the safety and well-being of

children and adolescents.

Teacher and

Provide training and resources to teachers, school counsellors and

education staff

other education-based workers to build mental health literacy and

capacity to support

skills to support the mental health and social and emotional learning of

student mental

children and adolescents.

health

Implement programmes to support the mental health and well-being

of teachers and education-based workers.

Mental health promotion: Ensuring an enabling and safe environment

Community engagement and participation

DOMAIN

ACTION

Community-based

Implement campaigns to address mental health-related stigma and

mental health

discrimination.

promotion

Train community-based workers, volunteers, young people, religious

and community leaders and educators to raise awareness about

mental health, promote mental health literacy, and address harmful

social and gender norms.

Build the capacity of adolescents and provide opportunities for them to

participate in the planning, design and evaluation of MHPSS policy and

programmes, and mental health advocacy (including adolescents with

lived experience of mental health needs).

Supportive mental health-related policies and legislation

DOMAIN

ACTION

Policies, strategies

Assess and address the barriers for children and adolescents in

and plans for child

accessing mental healthcare, particularly for marginalized groups.

and adolescent

Strengthen the National Mental Health Strategic Plan to provide

mental health

greater details on a multi-tiered and multisectoral vision and plan

for child and adolescent mental health, and develop and adopt a

multisectoral (costed) implementation plan with specific goals, actions

and performance indicators for child and adolescent mental health.

Introduction

Ensure sufficient allocation of public resources to implement the

national policy through detailed costing, defined budget lines, and

allocation and expenditure tracking across all key sectors.

Adopt a multisectoral, national suicide-prevention plan and integrate

prevention of suicide and self-harm across child and adolescent health,

development and welfare programmes.

Integrate mental health into child and adolescent health, nutrition, and

maternal and child health policies and plans.

Strengthen the integration of mental health into early childhood

development, child protection/ending violence, social welfare and

social protection policies and plans with clear roles and actions in

relation to MHPSS.

More explicitly integrate mental health into education sector policies

and plans and develop a whole-of-education policy for mental health

promotion.

Strengthen the integration of mental health of children and

adolescents into juvenile justice with clear roles and actions in relation

to MHPSS.

Legislation and

Adopt policies that define high-quality mental healthcare for children

actions required

and adolescents (minimum standards of care) that include relevant

for effective mental

sectors and government, non-government and private providers.

health services

Adopt legislation and develop implementation guidance that ensures

children’s and adolescents’ right to access mental health services

in accordance with their evolving capacities and in a manner that

protects confidentiality. This includes legislation supporting the right of

adolescents to access care without mandatory parental consent.

Adopt legislation that mandates access to mental healthcare for

children and adolescents who are deprived of liberty, in conflict with

the law or in out-of-home placements.

Address legislation that denies access to mental healthcare for

migrant, displaced or other marginalized children and adolescents.

Remove legislation that criminalizes suicide or attempted suicide.

Legislation to

Prohibit physical restraint of children and adolescents with acute

protect children and

mental conditions in home, school, healthcare or any other settings

adolescents within

providing services or care.

the mental health

Adopt protections (legislation, regulation, monitoring and complaints

system

mechanisms) to ensure that deprivation of liberty, including detention

for mental health purposes, is a last resort, for the shortest appropriate

period, and subject to periodic review.

Policies,

Prohibit all forms of violence (physical, sexual, emotional) against

programmes and

children and adolescents in all settings, including home, school,

legislation to

online and in places of alternative care and detention, including use of

protect children

corporal punishment.

and adolescents

Prohibit early marriage of children under the age of 18 years.

from harm and

discrimination

54 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Prevent and eliminate child labour (defined as work that deprives

children of their childhood, their potential, their dignity, and is harmful

to physical health or mental development).

Prohibit the association with and recruitment of children and

adolescents into armed forces/groups.

Legislate a minimum age of purchase of substances (alcohol and other

drugs). Introduce alternatives to criminalization of possession and use

of substances by adolescents under the age of 18 years.

Adopt legislation that restricts access to lethal means (firearms,

poisons, drugs).

Increase the minimum age of criminal responsibility (UNCRC

recommends at least 14 years).

Adopt legislation to protect children and adolescents from

discrimination on the basis of gender identity or sexual orientation, and

decriminalize consensual sexual acts.

Adopt legislation to prohibit discrimination on the basis of gender, race,

ethnicity, religion, disability, nationality, political affiliation or geographic

location.

Implement social protection programmes (social insurance, social

protection schemes and other means) with a focus on families and

carers of children and adolescents.

All actions proposed in the regional conceptual framework were considered a high priority for

inclusion in an MHPSS package for Malaysia. While progress has been made to introduce many of

these actions, stakeholders across sectors noted significant challenges impacting implementation,

particularly at scale, and a need to strengthen coordination and delivery.

The highest priority was given to actions related to responsive care. Improving early identification

and screening beyond traditional healthcare settings (such as in schools, community-based services

and through self-referral) is essential. However, it is critical that screening occurs in the context of

a strong referral system and accessible services and supports. As such, stakeholders considered

strengthening the referral system and increasing the availability of child and adolescent mental health

services (including community-based services) among the most pressing priorities for MHPSS.

Improving multidisciplinary, person-centred care was also a priority, with many stakeholders noting

that the current approach focuses primarily on individual-based clinical treatment, with a significant

need for services that extend beyond clinical management to include social support and care for

parents and families.

The next highest priority were key actions related to prevention. Among these, school-based

actions (from early education through to secondary education and higher) were considered central

to preventing poor mental health and enhancing protective factors. High priority actions included:

developing and implementing programmes to address violence and bullying; curriculum-based and

other programmes to promote positive peer relationships; programmes to address the harmful use of

substances; and implementing curriculum-based and other programmes (for example, strengthened

life skills education) to support social and emotional learning and skills. Similarly, high importance

was placed on strengthening the quality and coverage of parenting programmes to support positive

parenting and improve mental health literacy and care-seeking.

Among actions related to ensuring a safe and enabling environment, high priority was given to

campaigns and programmes to address stigma and discrimination and harmful norms, noting that

stigma remains a significant barrier to seeking services and supports. The importance of engaging

Introduction

young people and community leaders with training and education around mental health and supporting

greater participation of young people in the planning and design of MHPSS were rated as high

priorities among youth representatives. Other stakeholders across key sectors also noted the need

to more explicitly integrate mental health into key sectoral policies, with clear descriptions of roles,

responsibilities and accountabilities. Strengthening or amending legislation to protect children and

adolescents from harm was also prioritized. Decriminalizing suicide was also identified as a priority

because it is seen as a key barrier to care-seeking and a contributor to stigma. Another high priority

was removing mandatory parental consent requirements as this creates a significant barrier to

accessing care for adolescents.

Stakeholders also identified priority actions for the short term (within two years), mid-term (two to

five years) and long term (more than five years):

FIGURE 13. ACTIONS FOR SHORT-TERM IMPLEMENTATION

Actions given the highest priority for implementation in the next two years:

Screening those with high-risk behaviours and exposures

Screening for pregnant and postpartum adolescent girls

Strengthening self-referral through helplines/hotlines/online

Specialist support, case management and therapy by multidisciplinary team

Specialized services and support to families of children with complex behaviours /

needs, in social services, justice settings

Specialist clinical mental health treatment and care

Person-centred care that includes social support, peer support and mental health

professionals

Establishing peer-to-peer groups and youth clubs for children and adolescents both

in-school and out-of-school

Implementing selective intensive school-based and out-of-school programmes

targeted for children and adolescents who are at risk of poor mental health. Can be

packaged with counselling and referral to services

Designing and delivering stigma and discrimination reduction campaigns

Training community health workers, community volunteers, adolescents, religious

leaders and educators to raise awareness about mental health to address harmful

social norms

Providing capacity building opportunities for adolescents, including those with lived

experience, to be engaged in the planning and design of MHPSS

56 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

FIGURE 14. ACTIONS FOR MEDIUM-TERM IMPLEMENTATION

Actions given medium priority for implementation within two to five years:

Sensitizing school-based counsellors and social services to identify those with

mental health needs

Training and sensitizing frontline and community workers to identify, support

and refer

Establishing referral criteria and mechanisms within the health sector and from

other sectors/settings

Integrating mental health into physical health services

Child, adolescent and family-friendly services that are inclusive

Community-based and mobile services for hard-to-reach children and adolescents

Residential rehabilitation services

Ongoing participation in education for those with mental health problems

Guidance and support for schools on effective interventions following crisis (such

as suicide in community)

Supporting teacher well-being

Raising awareness on nurturing care, positive parenting and non-violent discipline

Designing and implementing parenting programs focused on building skills to support

nurturing care, positive parenting practices and non-violent discipline

Identifying and addressing the mental health needs of parents/guardians/carers

Addressing peer victimization, including through digital media (universal)

Adopting a national mental health strategy/policy that details the multi-tiered

and multi-sectoral vision and plan for mental health, and adopt a multisectoral

implementation plan (including coordination)

Integrating mental health into the education sector policy and plan

Integrating mental health into early childhood development, child protection/

ending violence against children, social welfare and social protection policies,

strategies and plans

Introduction

FIGURE 15. ACTIONS FOR LONG-TERM IMPLEMENTATION

Actions given priority for implementation in the next five years:

Education and support for parents of children and adolescents with mental health

needs

Implementing a whole-school approach to mental health and well-being

Implementing a ‘whole-school/education’ approach to tackling violence and

bullying

Designing and implementing school substance use policies

Promoting teacher-parent communication on the safety and well-being of children

and adolescents

Providing training and resources for teachers to provide environments that meet

the learning, well-being and safety needs of children and adolescents

Implementing universal psychosocial interventions in schools and out-of-school

settings that focus on building social and emotional skills, positive behaviours, school

connectedness, effective problem-solving, help-seeking hehaviours and address risk

factors

Adopting legislation and actions required for effective mental health services for

children and adolescents

Implementing laws that protect children and adolescents within the mental health

system

Implementing policies/programmes and strategies that protect children and

adolescents from harm and discrimination

58 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

Table 4 provides an overview of the key roles of the health, education, social welfare and justice

sectors in implementing the priority package of MHPSS actions. The health sector was identified as

having an overarching leadership role with respect to setting national policy, planning and oversight

of MHPSS. However, stakeholders across sectors described a critical role for the education, social

welfare and justice sectors in terms of prevention and promotion, as well as supporting a strong

referral system.

Table 4. Sectoral roles in implementing MHPSS actions: Accessible and responsive care for mental health

conditions

Actions in bold indicate where a sector is recommended to have a leading role or primary responsibility for

implementation

Accessible and responsive care for mental health conditions

HEALTH

EDUCATION

SOCIAL WELFARE

JUSTICE

Screening for those

Early identification

Screening for children

Screening for high-

at risk, including

of those with mental

and adolescents with

risk behaviours and

parents/caregivers

health conditions or

high-risk exposures

exposures

with mental health

risks

(and parents/

conditions

caregivers) with high-

risk exposures

Referral systems

Referral linkages

Referral linkages and

and mechanisms

mechanisms

(referral criteria

(particularly protocols

Self-referral hotlines

and protocols both

for referral of children

within the health

identified through

system and from

schools for health

other sectors/

or social welfare

settings (schools,

services)

social welfare/child

protection, justice))

Self-referral hotlines

Multidisciplinary

Ongoing education

Multidisciplinary case

Specialized services

case management

participation for those

management

and supports,

and support

with mental health

including mental

Targeted education

conditions

health services in

Targeted education

and support for

detention settings

and support for

parents of children

with mental health

conditions and

complex behaviours

Community-based

and outreach

and outreach services

services

Establishing

specialized and

specialized

clinical services

services and case

management for

families

Establishing

Supporting residential

residential services

mental health

services

Introduction

Responsive care: Health sector

For the provision of accessible and responsive care for mental health conditions, the health sector plays

the most prominent role among all the key sectors. Most stakeholders recommended that the health

sector take the lead role in responsive care, with support from the other sectors in different subdomains

such as the provision of technical support and coordination of community-level programmes.

Screening for at-risk populations (for example, children and adolescents impacted by substance

use and family violence, marginalized children and children orphaned by the COVID-19 pandemic)

was identified as the primary responsibility of healthcare providers. Stakeholders emphasized that

screening must be supported by a strong referral system with mechanisms that facilitate self-referral

or inter-agency referral from the education, social welfare or justice sectors. The health sector was

identified as having overarching responsibility for developing guidelines, procedures and protocols

for referral within the health sector and between health and other sectors (including a public-private

linkage in view of the two-tier healthcare system in Malaysia).

Stakeholders also described an urgent need for the health sector to expand specialized clinical services

for children and adolescents, including residential care. The majority of specialized psychiatrists (with

sub-specialization qualifications) are based in the private healthcare sector, which receives a lower

percentage of patients compared with the public health sector. This group of specialized mental health

experts was identified as being important for improving the accessibility of mental healthcare, as

well as providing training and support to other health providers. While the health sector has primary

responsibility for technical guidance and policy related to MHPSS in addition to implementation of

health services, stakeholders also identified a critical coordinating role for the sector in terms of

improving linkages and collaboration with the education, social welfare and justice sectors and NGOs

to support multidisciplinary care.

Responsive care: Education sector

The education sector was identified as playing an important role in implementing early identification

and screening, particularly given that teachers and school counsellors are often the first to respond

to behavioural problems and mental health concerns. To support this, stakeholders recommended

that school-based counsellors and other staff involved in social services in the education sector have

access to training and supervision (for example, from psychiatrists and psychologists) specifically in

relation to mental health and the use of screening tools. The education sector was also seen to be

a critical part of a strong referral system - this is particularly important as school-based screening in

the absence of accessible services and support can be harmful and stigmatizing. Additionally, the

education sector was recommended to have responsibility for ensuring the inclusion of children and

adolescents with mental health conditions in the formal education system.

Responsive care: Social welfare sector

The social welfare sector was identified as having a key role in the provision of responsive care at

the community level. Stakeholders described community-level care as being equally as important

as institutional-level, health-facility care due to the possibility of long-standing or recurrent mental

health conditions. The social welfare sector can be the primary source of social support and peer

support to deliver person-centred care for adolescents and children in need. This sector is also the

best placed to work with NGOs to ensure that access to education and continuous support can be

provided to children, parents and families via community-based and mobile services.

The DSW, through the Children’s Division, has established a strategic partnership with communities

throughout the country that includes a programme as follows:

a. Child Protection Teams (PPKK) - 140

b. Child Welfare Teams (PKKK) - 133

c. Assistant Protector - 299

62 Strengthening Mental Health and Psychosocial Support systems and services for

children and adolescents in the East Asia and Pacific region: Malaysia Country report 2022

STRENGTHENING MENTAL HEALTH AND PSYCHOSOCIAL SUPPORT SYSTEMS AND SERVICES. MALAYSIA COUNTRY REPORT 2022 - page 1