Child and adolescent mental health services in crisis, report finds
Plans are underway for a study to determine South Africa’s public mental health system’s ability to cater for the needs of children and adolescents with mental health problems. National Department of Health spokesperson Foster Mohale tells Spotlight the study findings and recommendations will contribute toward improved mental health services for this age group.
He could not provide much detail as the study will be commissioned later this financial year.
Foster was responding to Spotlight’s request for input on the Child Gauge report that the University of Cape Town’s (UCT) Children’s Institute released recently. 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 children in the country.
What the Gauge found: The numbers
The latest edition of the South African Child Gauge focuses on child and adolescent mental health and how early experiences of adversity can affect people throughout their lives, often with great costs to the individual 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 ten children diagnosed with a mental condition that is treatable will have access to care. Which causes a ripple effect where children, in the absence of support and the necessary care, struggle at school and eventually drop out which has serious implications for their economic prospects. Statistics from UNICEF South Africa’s U-Report also show that “65% of young people with mental health issues did not seek help”, so many children and adolescents fall through the cracks.
— Children's Institute (@CIatUCT) June 24, 2022
Other statistics highlighted in the report show that “two-thirds of children in the country live in poverty and nearly one in two children have experienced violence, including physical violence and sexual abuse”.
Professor Shanaaz Matthews, Director of the Children’s Institute at UCT in a press statement said, “These children and adolescents are at particular risk of poorer mental health, which can perpetuate an intergenerational cycle of poverty, violence and ill-health. Given the scale and intergenerational nature of violence against children, our response to trauma needs to extend beyond dedicated psychological and psychiatric services.”
Speaking to Spotlight, Professor Mark Tomlinson, co-director at the Institute for Life Course Health Research in the Department of Global Health at Stellenbosch University says that part of what they wanted to do with the Gauge was to provide a broader view of what’s needed to create conditions where children and adolescent can thrive and flourish.
two-thirds of children in the country live in poverty and nearly one in two children have experienced violence, including physical violence and sexual abuse
Tomlinson says that many services in government that are key for mental health would never be seen as mental health interventions. Such as having non-judgmental, caring health services for adolescent 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 says.
Expanding access: Services in schools
Tomlinson says part of creating conditions for children to flourish is better services. “The Western Cape has quite a number of really good in-patient units, Gauteng as well, but in Mpumalanga, Limpopo, and in other provinces there is next to nothing. The services when something goes very wrong are really key,” he says.
“But we are also trying to make a case that’s broader than that and more complex. We really need to see mental health like a continuum where, only on one end, you need the services and along that continuum, you need different things,” he says, adding that schools also need to be equipped to deal with issues.
Families and schools are very good platforms to nurture good mental health, Tomlinson says. This doesn’t mean teachers must be psychologists, only that schools are a great setting to “create a good environment for mental health”.
He explains that what can help is teachers creating an environment where it is easy for learners to talk to them and them talking openly with learners. “This is not extra work at all. In turn, when the environment is conducive, it even becomes easy to teach,” he adds.
Mohale says the health department has put in place a number of interventions and plans to increase access to, and improve the quality of mental health, including early identification, treatment and rehabilitation services to “tackle the effects, as well as to make the services available for children and adolescents”.
Part of the intervention from the health department includes integrated school mental health services and integrated community health worker services, he says. “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 learners with mental health problems,” says Mohale.
Professor Sharon Kleintjes, Professor of Intellectual Disability in the Department of Psychiatry and Mental Health at UCT, acknowledges that there are already a number of valuable policies and programmes in place to promote mental health. Kleintjes in a statement lists among these the “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 coordination, however, remain a challenge,” she says, “and greater efforts are needed to improve the physical and psychological health of the school, and to strengthen links to health services and other community resources.”
Mohale says that although there was progress through implementing the now lapsed Mental Health Policy Framework, a lot still needs to be done. “Not all that was intended by the mental health policy framework was achieved, especially at the implementation level,” he says. “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”. Reflecting on resources for mental health services for young people, the report states that there are only a few child and adolescent psychiatrists and mental health professionals and most of them work in urban centres and the private sector.
In a recent answer to a written parliamentary question, health minister Dr Joe Phaahla said that 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 a province like the Eastern Cape, there are only two filled psychiatry posts in the public sector, Phaahla said. This meant a ratio of one psychiatrist to over three million people in the public sector.
He did not specify the breakdown for children’s mental health services.
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”, which includes developing a long-term vision for these services.
Some of the recommendations in the report include creating specific multidisciplinary teams in districts that can promote mental health literacy and, in so doing, also care-seeking behaviour among this specific age group. The report states 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 that 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 states.
For all this, strong provincial leadership is needed to build capacity, steer clear implementation plans, and create a ring-fenced budget for these services – something experts and activists have advocated for some time. The report states that 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”.
Outlining the department’s various interventions to improve access to mental health services, Mohale says there is 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, which is nearer to where young people live and school.
According to him, the health department is “collaborating with the Foundation for Professional Development (FPD) to train medical doctors and professional 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”. Over 2000 professionals have been trained and capacitated as part of this project, he says.
Include young people in decision-making
According to Bharti Patel, National Executive Director of the South African Federation for Mental Health, the Child Gauge can help advocate for evidence-based strategies regarding improved mental health for children in South Africa.
“We need every government department to think about how their policies and programmes are youth-centered and youth-friendly. We need departments to meaningfully 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 stringently monitor mechanisms and accountability structures for when departments fail to achieve what they have been mandated to achieve regarding youth wellbeing,” she says.
— anna-marie müller (@annamarie_mza) June 15, 2022
South Africa’s Mental Health Policy Framework and Strategic Plan which lapsed in 2020, suggests that mental health promotion and prevention initiatives that target key developmental stages can assist to break the cycle of poverty and mental ill-health through improving resilience.
With a new framework now under review, Patel says, “It should take heed of the evidence provided by this Gauge and other recent policies and research regarding child wellbeing, especially when it comes 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 tells Spotlight that the lapsed mental health policy is under review and provides eight “catalytic objectives to ensure improved mental health services for all strengthens the focus on issues of child and adolescent mental health service provision as one of the priority target group”.
“Child and adolescent mental health services will remain a priority even in the revised framework. The plan is to come up with a policy that is integrated and promotes collaboration with key sectors like the Department of Basic Education and Social development as well as civil society working in the field of mental health. 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, Mohale says.
*READ the department’s full response here.