Plans are under way for a study to determine South Africa’s public mental health system’s ability to cater for children and adolescents with mental health problems, write Tiyese Jeranji and Alicestine October in Spotlight.
National Department of Health spokesperson Foster Mohale said the findings and recommendations of the study, which would only be commissioned later this financial year, would contribute toward improved mental health services for this age group.
Foster was responding to Spotlight’s request for input on the Child Gauge report recently released by the University of Cape Town’s (UCT) Children’s Institute.
This report, however, already highlights the needs of children with mental health conditions and makes important recommendations on how the public health system can respond to meet those needs. The Gauge is an annual review of the situation of South African children.
What the Gauge found: The numbers
The latest edition focuses on child and adolescent mental health and how early adversity can affect people throughout their lives, often with great costs to them and society.
The report cites statistics showing that “even with the best possible mental health promotion and prevention strategies, approximately 10%-20% of children and adolescents will develop a mental disorder and/or a neurodevelopmental disability”.
In South Africa, however, only one in 10 children diagnosed with a treatable mental condition has access to care. This causes a ripple effect – without support and the necessary care, they struggle at school and eventually drop out, with serious implications for their economic prospects.
Statistics from UNICEF South Africa’s U-Report also show “65% of young people with mental health issues did not seek help”, so many fall through the cracks.
The reports also shows that “two-thirds of children in SA live in poverty and nearly one in two have experienced violence, including physical violence and sexual abuse”.
Professor Shanaaz Matthews, director of the Children’s Institute at UCT, said: “These children are at particular risk of poorer mental health, perpetuating an intergenerational cycle of poverty, violence and ill-health. Given the scale and nature of violence against children, our response to trauma needs to extend beyond dedicated psychological and psychiatric services.”
Professor Mark Tomlinson, co-director at the Institute for Life Course Health Research in the Department of Global Health at Stellenbosch University, told Spotlight part of what they wanted to do with the Gauge was provide a broader view of what’s needed to create conditions where children and adolescents can flourish.
He said that many government services that are key for mental health would never be seen as mental health interventions, such as having non-judgmental, caring health services for girls seeking abortions. “That is not seen as a mental health intervention but it’s a massive mental health intervention because if she doesn’t get that, her risk of developing a mental health disorder is massive,” he said.
Expanding access: services in schools
Tomlinson said part of creating conditions for children to flourish would be better services. “The Western Cape has some good in-patient units, Gauteng as well, but in Mpumalanga, Limpopo, and in other provinces there is nothing. Schools also need to be equipped to deal with issues.”
Families and schools are good platforms to nurture good mental health, but this doesn’t mean teachers must be psychologists, “only that schools are a great setting to create a good environment for mental health”.
Mohale said the health department had put in place various interventions and planned to increase access to, and improve the quality of mental health, including early identification, treatment and rehabilitation services.
This includes integrated school mental health services and integrated community health worker services, he said. “Screening and referral of learners for mental health programmes are integrated into the school health policy and programme to ensure early identification, care, treatment and rehabilitation, including referral of children with mental health problems.”
Professor Sharon Kleintjes, professor of Intellectual Disability in the Department of Psychiatry and Mental Health at UCT, said there were already policies and programmes in place to promote mental health, including, “focus on life skills in the school curriculum, a national school safety framework to prevent violence, care and support for teaching and learning, and school health services”.
“Implementation and co-ordination, however, remain a challenge,” she said. “Greater efforts are needed to improve the physical and psychological health of the schools, and strengthen links to health services and other community resources.”
Mohale said although there was progress through implementing the now lapsed Mental Health Policy Framework, much needed to be done. “Not all that was intended by the framework was achieved, especially at implementation level,” he said. “Provinces cited a shortage of resources both human and financial for non-achievement of some objectives.”
Expanding access: health services
The Gauge stresses that “child and adolescent mental health services are in crisis”. There are few child and adolescent psychiatrists and mental health professionals in the country, and most work in urban centres and the private sector.
In a recent answer to a written parliamentary question, Health Minister Dr Joe Phaahla said it “is estimated that 6 566 703 persons need care for common mental disorders and 1 292 991 of those aged 15 years and older need care for severe psychiatric conditions”. In the Eastern Cape, there are only two filled psychiatry posts in the public sector, Phaahla said. This meant a ratio of one psychiatrist to more than 3m people.
An important plea in the Gauge is to move from “describing the problem to thinking (about) how to strengthen services and systems for children and adolescents”, including developing a long-term vision for these services.
Recommendations in the report include creating specific multi-disciplinary teams in districts to promote mental health literacy and, in so doing, also care-seeking behaviour among this age group. The report suggests that ideally these teams must include “a child and adolescent psychiatrist, psychologist, speech and language therapist, occupational therapist, child and adolescent mental health nurse practitioner, social worker and dedicated link professionals from the Departments of Basic Education, and Social Development”.
“To staff the district CAMH teams, child and adolescent psychiatry would need to be reclassified as a ‘specialty’ rather than as ‘sub-specialty’ in the same way Paediatrics became distinct from General Medicine. This would reconceptualise Child and Adolescent Psychiatry as a community speciality, rather than as a highly specialised (‘sub-specialist’) discipline,” the report said.
But strong provincial leadership is needed to build capacity, steer clear implementation plans, and create a budget for these services – something experts and activists have advocated for some time. The report said child and adolescent mental health services must also be included in “the proposed basket of care under National Health Insurance to uphold children’s rights to basic mental health care and financial risk protection”.
Mohale said there was additional funding through the NHI Grant to contract private psychiatrists, psychologists, registered counsellors, social workers, and occupational therapists to complement staff at primary health care facilities to increase capacity to provide mental health care services at this level, closer to where young people live and school.
The health department is “collaborating with the Foundation for Professional Development (FPD) to train medical doctors and nurses working in general health facilities to further improve their skills in clinical management of mental disorders among all population groups including children and adolescents”. More than 2000 professionals have been trained and capacitated as part of this project, he said.
Include young people in decision-making
Bharti Patel, national executive director of the South African Federation for Mental Health, said the Child Gauge can help advocate for evidence-based strategies regarding improved mental health for children.
“We need every government department to think about how their policies and programmes are youth-centred and youth-friendly.
They must include young people in their decision-making processes, to take ownership of what is within their jurisdiction regarding service delivery for young people, and to monitor mechanisms and accountability structures for when departments fail to achieve what they have been mandated to achieve regarding youth well-being,” she says.
South Africa’s Mental Health Policy Framework and Strategic Plan, which lapsed in 2020, suggests mental health promotion and prevention initiatives targeting key developmental stages can help break the cycle of poverty and mental ill-health through improving resilience.
With a new framework now under review, Patel says, “It should heed the evidence provided by Gauge and other recent policies and research regarding child well-being, especially relating to possible relevant interventions to target mental health among young people. Including young people in the redrafting of the new framework is also essential.”
Mohale told Spotlight the lapsed mental health policy was under review and provides eight “catalytic objectives to ensure improved mental health services for all”.
“Child and adolescent mental health services will remain a priority even in the revised framework. The review is also taking into consideration the findings and recommendations by the South African Human Rights Commission regarding services for child and adolescent mental health,” he added.
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Spotlight article – Child and adolescent mental health services in crisis, report finds (Republished under Creative Commons Licence)
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