Invest early in children’s mental health – or risk a generation

As mental health risks for children and adolescents escalate in the wake of COVID-19, the message of the 2021/2022 South African Child Gauge is clear: invest – and invest early – in children’s well-being across multi sectors for the world’s future prosperity.

The 16th issue of the annual publication is titled “Children’s mental health: A catalyst for development”, and was launched on the eve of Youth Day in South Africa, and the Day of the African Child.

The South African Child Gauge is published by the University of Cape Town’s (UCT) Children’s Institute (CI). Its partners are the United Nations Children’s Fund (UNICEF) South Africa, the Department of Science and Innovation–National Research Foundation Centre for Excellence in Human Development, the University of the Witwatersrand, the Standard Bank Tutuwa Community Foundation and the LEGO Foundation.

Professor Sharon Kleintjes of UCT’s Department of Psychiatry and Mental Health, the CI’s Lori Lake, and Professor Mark Tomlinson, the co-director of Stellenbosch University’s Institute For Life Course Health Research, are the issue’s co-editors.

The hybrid launch held on campus was led by Associate Professor Tracey Naledi, the deputy dean of health services in the Faculty of Health Sciences. Ten guest speakers in fields as diverse as law and paediatrics shared their synopses of the challenges and opportunities for South Africa, Africa and the world against a backdrop of climate change, new wars, impending food shortages and threats to human freedoms.

The publication calls for a holistic societal response to protect children, build their capacity to cope with stress and adversity, and provide opportunities to thrive. Responses must be multi-layered and multi-sectoral, pooling human and capital resources to achieve sustainability.

CI director, Professor Shanaaz Mathews, said the publication’s role, as an advocacy tool, had shaped its annual message and the themes of its multi-authored chapters. A “mammoth task”, this edition had harnessed the expertise of over 90 contributors.

It played a key role in protecting the rights of children, said Professor Linda Richter of the DSI–NRF Centre of Excellence in Human Development at Wits.

“The Child Gauge has been absolutely steadfast in its approach to ensuring we understand how laws are changing, what data is available and focusing on an issue that enables us to work together to realise children’s rights.”

But COVID-19 has been a major setback to these rights, disrupting children’s routines, education, recreation and support structures, said guest speaker Christine Muhigana, country representative, UNICEF South Africa.

As the pandemic continues to shape reality, the focus on youth and mental health has become critical, she said. However, too often the picture of children’s mental health is skewed towards the world’s wealthier countries.

“This means that we know too little about how children in poorer countries experience mental health.”

Mental health a holistic issue

Muhigana pointed to UNICEF’s recent European Union polls, which showed that 65% of young people experience some form of mental health issue.

“It is estimated that more than 13% of adolescents aged 10 to 19 live with a diagnosed mental disorder,” she said.

This represents 86 million adolescents aged 15 to 19 and 80 million adolescents aged 10 to 14. Anxiety and depression make up about 40% of these diagnosed mental disorders. Others include attention deficit hyperactivity, autism, schizophrenia, intellectual disability as well as bipolar, conduct eating, and personality disorders.

“Despite these concerning figures, globally about 2% of government health budgets are allocated to mental health spending, less than US$1 per person in some of the poorest countries.”

The inclusion of mental health in the Sustainable Development Goals needs global and national actors to recognise mental health as a holistic issue, relevant to every sector of development.

“We need to ensure that mental health indicators are present in national health information systems and in programme evaluation,” added Muhigana. “Crucially, we need to improve our data collection, routine monitoring and research, as the Children’s Institute continues to do.”

Too few services

A country at war with its children through high levels of violence would only aggravate conditions for poor mental health among children, said speaker Dr Yogan Pillay. Dr Pillay is the country director of the Clinton Health Access Initiative. He cited a South African Police Service report, which reflected 6 000 murders in the first quarter of this year.

“We must take a right-based approach to mental health for children and adolescents.”

“This has knock-on effects for children who are directly and indirectly affected.”

Many young people experiencing mental health problems do not seek help either, he said. The problem is compounded by the limited psychosocial services available to them. South African research published in 2018 had found that none of the nine provinces has a child and adolescent mental health policy – or an implementation plan to support national policy.

“Despite [the fact that] one in five children and adolescents suffer from mental disorders, which often persist in adulthood, only 10% of this group receives the necessary help.”

He added, “We must take a right-based approach to mental health for children and adolescents.”

This calls for a comprehensive, fully funded package of care spanning the continuum of need, from community-based mental health services to in-patient services. It should also include non-citizens. The National Health Insurance Bill under discussion in Parliament could provide important legislation to improve access to mental health care, said Pillay.

“We need to use this window of opportunity.”

Schools are crucibles

Professor Kleintjes said factors such as poverty, food insecurity, inequality, discrimination, violence, climate change and other humanitarian emergencies (such as an insurrection and two floods in KwaZulu-Natal) aggravated risk along the continuum of mental health status.

“But adequate care can prevent a child at risk on the continuum moving into an unhealthy state.”

She also pointed to a neglected sector: children with disabilities, who face additional trauma, stigma and exclusion and need more support and disability-specific interventions.

“We must recognise the whole system of connected community structures, with the home as a site of intervention as well as schools, NGOs and faith-based organisations in the community as partners to supporting children and adolescent mental health.

Here schools should be frameworks for mental health interventions.

“Schools are where children congregate and offer a captive audience for a large part of the day. There, we could be looking at mental health interventions and normalising the need to see mental health as part of [a system of] holistic care.

“This must be supported by strong government policies and resources, sound school benevolence and partnerships with local communities.”

Start early

It’s important to start the process of care and intervention early, said Professor Tomlinson. Over 50% of all adult mental disorders have their origin before the age of 14, he noted.

“The prevention work can’t start at the diagnosis stage. It must start earlier, and it must start everywhere. In terms of the Child Gauge’s title, it is everyone’s business and we’re all involved.

“There’s nowhere in the world where families are not the bedrock of everything.”

Families are critical to the process.

“There’s nowhere in the world where families are not the bedrock of everything. And we mean families in every type of form they exist in; the function is more important than the form. When a child feels safe, loved, heard and they feel they’re in an enabling environment, that sets up a fantastic environment for the future. And while it may not be a vaccine, it lays a foundation.”

Communicating about mental health and well-being is also essential. Although COVID-19 created havoc, it taught the world about the benefits of digital communication. This should be harnessed in the campaign for mental health.

Tomlinson cautioned against researchers’ tendencies to “admire the problem”.

“We need to focus on what can be done now, and what with COVID–19 and Putin [war in the Ukraine] and climate breakdown, it’s a difficult time. But difficult times offer important opportunities to do something different. And so, we’ve made the case [in the South African Child Gauge] for putting children and adolescents at the centre, not just of mental health, but of everything we do.”