Concerned experts have pointed out the serious gaps in psychiatry regarding the treatment, prevention and care for children and adolescents in South Africa, saying these services should be offered in Afro-centric and culturally sensitive ways.
Additionally, there is a worrying shrinkage of qualified specialists to help these youngsters.
“We have a mental health crisis in this country and yet, there are fewer than 40 registered child psychiatrists,” said Dr Anusha Lachman.
In Spotlight, Sue Segar writes that Lachman is the first child psychiatrist to hold the position as president of the SA Society of Psychiatrists (SASOP), and her goals are to prioritise the “grossly under-represented and under-resourced” field of child and adolescent health.
While the field is certainly neglected, Lachman is not alone in trying to draw more attention to it – the 2020/2021 edition of the Children’s Institute’s excellent Child Gauge also concentrated on the mental health of South African children.
Lack of data
Lachman said one of the biggest issues was the lack of reliable data – that most of the current research, literature and thinking about infant mental health focused on Western, high-income settings but her focus is on the African context and in limited-resource settings.
“We don’t have many figures on how many young people are suffering from the various mental health disorders,” she added.
Insight into the country’s mental health crisis is partly gauged from the number of referrals to primary health care centres for mental health support and evidenced by the long waiting lists for children to be assessed at specialist mental health clinics and hospitals.
“All we have, across our public hospitals, is the waiting list data, telling us only how long children with severe mental illness wait to get into secondary and tertiary level hospitals for hospital-based care.”
But these data tell us little about the vast majority of adolescents with mental health issues who do not require hospitalisation.
Lachman also heads the Clinical Unit Child Psychiatry at Tygerberg Hospital, the province’s only tertiary hospital-based assessment unit for adolescents between 13 and 18 with complex psychiatric presentations and severe mental illness. The young people they help often face not only mental health issues, but the full range of psychosocial challenges – from poverty to exposure to violence, substance abuse, and HIV.
“We know, for example,” she said, “what substance-use disorder looks like in children under 12 and in under-21s, because we get that from substance-use centres and rehabilitation centres. We know what proportion have HIV and TB and some infectious diseases, which, by extension, have psychosocial consequences and comorbidities, and we know about neurodevelopmental delays, because we track things like school attendance and requests for access to support in special needs.
“We do have statistics on issues which affect children in South Africa disproportionately,” she said, “on food insecurity, intimate partner violence, instability in terms of accommodation etc.
“There are huge occurrences of abuse but there are inadequate services for children to be removed from those abusive homes, because we don’t have enough children’s homes or safety placements for example. So these are youngsters who are disproportionally disadvantaged, which in itself is hard to quantify – and the psychosocial support structures are just not there.”
She added that the Western Cape Department of Health & Wellness was making inroads into the lack of data by tracking and digitising child mental health statistics through its Child and Adolescent Mental Health Strengthening Project.
“This will provide some important data across provincial emergency rooms, and hopefully, that can roll out to the rest of the country so we can understand what children are presenting with.”
Hard to categorise
Lachman said child mental health is a function of multiple psycho-social stressors, structural problems, and fundamental relational challenges – and that’s hard to categorise.
“It’s a complex relationship between environmental stressors and vulnerabilities to mental illnesses.”
High risk environments – for instance, with violence, poverty, untreated mental illness in caregivers, food insecurity and economic burdens – predispose children to mental illness expressed commonly in mood disorders, anxiety and trauma responses.
“These take the form of poor functioning at school, learning challenges, suicide and self-harming attempts, drug-seeking behaviours and, in some instances, expressions of severe mental illnesses. ADHD is also commonly seen in this context.”
Lack of relevant research
Lachman bemoans the “distaste” for research originating from the global South. “The biggest problem is the inability to publish and compete in international journals, not because our research is inadequate but because there’s a distrust of information from the lower-middle income countries or the global South.”
Research by Stellenbosch University academic Mark Tomlinson several years ago showed that less than 3% of all articles published in peer reviewed literature included data from low- and middle-income countries, where 90% of children live.
Low number of child psychiatrists
Lachman said that in the past three years, South Africa has lost five child psychiatrists to New Zealand. “This is about the brain drain… targeted recruitment of qualified people (by) first-world or industrialised regions who can offer incentivised work opportunities with which we, in South Africa, cannot compete.”
Only one child psychiatrist is trained every two years. “And only from a university that can train them. Just four universities can do that here – Stellenbosch, Wits, UCT and Pretoria. It depends, after two years, if the student passes the exam or not …so that is why there are so few.” (Before training in child psychiatry, candidates first have to complete the normal training to become a medical doctor.)
“So far there were two who qualified in 2022 and one who qualified in 2023. At the beginning of 2023, we had lost five child psychiatrists to New Zealand and Australia.”
Recent stats show SA has fewer than 40 (child) psychiatrists in working environments, including those who have retired.
“We still have provinces with zero representation for child psychiatry. We recently deployed one to the Eastern Cape, but North West, Limpopo, Mpumalanga, have no qualified (child) psychiatrists.”
Yet, Lachman does not believe the only answer is to train more child psychiatrists. “The answer is more nuanced. It’s about upskilling and task shifting, and an openness to the idea that child and adolescent psychiatry is everybody’s business.
“Even if you’re an adult psychiatrist, a physician, a paediatrician, or a nurse, or somebody treating adults, it’s your job to be aware of mental health problems in children.
“I feel strongly about changing the narrative and moving away from the idea that it’s a specialist realm, because mental health is everybody’s business, and child mental health should be pervasive in terms of focus, across various sectors.”
She also believes psychiatric services should be offered in ways that are Afro-centric and culturally sensitive. This, she said, must include a diverse spectrum of input – so not just the mental healthcare providers who punt a specific model of medication and therapy, “but partnerships with the educators, community workers, caregivers and allied health professionals to be able to effectively attempt to support and re-think models that can work in our setting”.
She suggests exploring opportunities for children to be screened early, recognised, and offered treatment. For instance, nurses at Well Baby clinics – where babies get immunised – can be trained in child mental health.
“While checking the child’s growth and immunisations, they could also look at whether the child is making eye contact, or engaging in reciprocal contact. If this is not happening, they need to know what further questions to ask and what to do next.”
Similarly, mental health awareness and screening should be in schools.
“Why do we offer sexual education, but not address mental health issues? Just as we have so easily incorporated into school curriculums how people can get condoms, we need to ask them how they’re feeling, whether they feel isolated, want to harm themselves or want to die.”
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See more from MedicalBrief archives:
School children crying out for psychosocial support
Psychiatrists group urges government to spend more on mental healthcare
Child and adolescent mental health services in crisis, report finds
Report flags huge gaps in children’s mental health services