Child and adolescent mental healthcare has many gaps

Keep separate facilities for children and adolescents with mental healthcare needs: that’s the plea of University of Cape Town (UCT) PhD graduate Dr Stella Mokitimi this Mental Health Awareness Month, as she continues to advance this work at the primary level of healthcare.

Dr Mokitimi graduated with her PhD on 14 July 2021 for her work on the thesis topic “Child and adolescent mental health services in the Western Cape of South Africa: policy evaluation, situational analysis, stakeholder perspectives, and implications for health policy implementation”.

Through this research with her supervisor, Professor Petrus de Vries, Mokitimi was able to explore issues affecting children and adolescents requiring mental healthcare, and establish what their needs are. She currently works as a clinical programme coordinator for mental health and chronic diseases in Khayelitsha, where she has been stationed since May 2021.

“Dr Mokitimi’s PhD represented the most systematic and comprehensive ‘situational analysis’ of health policies, resources, the views of decision-makers, of service providers, and – importantly – the views of families and teenagers who had experienced CAMH (child and adolescent mental health) services. Her PhD findings identified some strengths and positives. However, it also identified many areas of challenges and gaps that require strengthening,” said Professor De Vries.

Grassroots-level study

Mokitimi said her study covered users of these services and grassroots-level service providers. She conducted focus group discussions and interviews with children, adolescents and their caregivers to get their perceptions of the mental health services available to them in the Western Cape. Those in the study sample were aged eight to 18 and were in a good mental state to be able to engage in meaningful conversation. This qualitative study took place in 2017.

She said her findings determined – among other things, such as a lack of financing, leadership, governance and resources – that there was a lack of infrastructure in the Western Cape for children and adolescents with mental health problems.

“Children with mental health problems should be treated separately, in child-friendly environments.”

“At all levels of care, including at primary and secondary levels of care, there is no dedicated separate infrastructure or services for children and adolescents with mental health problems. They are mixed with adults. The separate child and adolescent mental health services that are more ideal are only at [the] tertiary level of care. There is [a] lack of human resources for child and adolescent mental health services, with a shortage even more in the rural areas; that shows inequitable distribution of the little available resources,” said Mokitimi.

The effects of having children and adults in the same mental healthcare facilities are detrimental, putting children at risk of fear and trauma.

“Children with mental health problems should be treated separately, in child-friendly environments ... When you mix a child with a mentally disturbed adult, you could expose that child to an adult’s inappropriate psychotic behaviour. This becomes traumatic for the child. Children who are sitting and observing these behaviours in adult spaces, they become fearful, and we lose them. They become non-compliant. They think, ‘Is this going to be me?’”

Poor reception of child and adolescent mental health patients, and stigma, also emerged as issues.

“There are negative attitudes towards child and adolescent mental health, and [there’s a] lack of support for staff and service providers.

“There were external factors that came out too, such as stigma, violence [and] substance abuse, that contribute to the challenges that we are facing. Some of the stigmas around having a mental illness as a child … for example, if a child has ADHD, it becomes very difficult for the community to understand the diagnosis of the child. The child is viewed as being naughty.

“A child on medication, and who has to take medication at school, gets stigmatised at school for taking medication. That leads to non-compliance. Some children are called names because of the medication they are taking.”

A change for the good

But it is not a hopeless situation. Among Mokitimi’s findings, she determined that a few facilities were offering ideal services in primary-level healthcare, despite the challenges.

Also, a change in the situation is coming – the provincial government has appointed new leadership in this area. Byron la Hoe of the Western Cape Department of Health confirmed that they have appointed Dr Rene Nassen to a leadership role in this sector.

“Our top management has supported the appointment of Dr Rene Nassen as the Coordinator: Child and Adolescent Services for the province; Dr Nassen is still very involved in clinical work while we are sorting out the structures,” said La Hoe.

“Children and adolescents need support in stress management, and to manage their anxiety – by all means. They need hope. They need to be checked up on.”

Mokitimi approves. “At provincial level, this appointment is a big achievement. At district level, the clinics – the primary level of healthcare – are starting to design and create more ideal child and adolescent mental health services, including separating children from adults.”

She continues to pursue the work of care for children and adolescents with mental healthcare needs in her post.

“My role is to ensure the strengthening of mental health services for both children and the broader population in a substructure [in Khayelitsha), and to ensure the integration of mental health services into chronic diseases ... I have started in my new role as a mental health coordinator in Khayelitsha; I have started with the community mental health nurses, to develop separate child and adolescent mental health services. I am pushing for a separation of adults and children with mental health problems.”

De Vries added: “We are now at the point where we are able to engage with people in different communities to plan with them what we can do to improve services, pathways and therefore the lives of young people who live with mental health problems in our country.

“The potential impact of Dr Mokitimi’s work is huge. Her work can be the driver for positive change in policies, prioritisation of CAMH in the country, and in finding innovative strategies to strengthen the range of health systems gaps described in her work.”

This Mental Health Awareness Month, Mokitimi asks us to think about children who have lost family to the coronavirus.

“COVID-19 has heightened the rate of suicide among children and adolescents in various areas. It has heightened anxiety and depression as a result of the virus, disease and losses people have experienced. Think of how many children have lost their caregivers ... children, who are very helpless, finding themselves having to head families.

“Children and adolescents need support in stress management, and to manage their anxiety – by all means. They need hope. They need to be checked up on.”