Mandy Wigdorowitz & Tasneem Hassem
From the limited data available, at least 10 to 20% of 5 to 17 year old children and adolescents suffer from a mental health disorder, which often persists into adulthood (Flisher et al., 2012; Stancheva, 2018). Over the past few years, the prevalence and diagnoses of child and adolescent mental disorders have escalated, resulting in parents, teachers, and health professionals becoming increasingly concerned. As such, the need to address these concerns has resulted in the establishment of National Children’s Mental Health Awareness Day, which takes place on 10 May each year since 2005 (Pride Surveys, 2017). This campaign highlights awareness about the importance of children’s mental health and demonstrates that positive mental health is essential to a child’s healthy development (American Psychological Association, 2018).
Child and adolescent mental healthcare in South Africa poses a unique, context-specific problem since many children are exposed to environmental risk factors that are not conducive to healthy development. Some of these risk factors include heightened exposure to violence, poverty, household HIV/AIDS infection, and substance abuse (Flisher et al., 2012; Skeen, Macedo, Tomlinson, Hensels, & Sherr, 2016). To adequately and appropriately address child and adolescent mental health, the correct services need to be in place, along with qualified healthcare professionals to provide the best care for these individuals. Although the South African government has taken significant steps to establish the legal and policy framework for the provision of all-inclusive and community-based services for children and adolescents (RSA Department of Health, 2003), the implementation and delivery of these services to all children and adolescents in need is, at present, not attainable. Furthermore, because of the vulnerable position of the child or adolescent as well as the rights of the caregiver or legal guardian, the first port of call for mental healthcare assistance and intervention mainly relies on observers and carers of the child. Stancheva (2018, p. 1) explains that a primary reason for the heightened prevalence rates for childhood and adolescent mental disorders is “increased help-seeking by parents and young children, improved screening, improved recognition in schools and primary care, improved diagnosis, the growing number of professionals in child and adolescent mental health”.
In order to effectively meet the needs of a child or adolescent with a mental disorder, a multi-tiered approach has been suggested (Dogra, Parkin, Warner-Gale, & Frake, 2018; Spender, Salt, Dawkins, Kendrick, & Hill, 2016). Tier one consists of frontline services such as general practitioners, teachers, school doctors as well as voluntary health workers. These professionals are not recognised as primary mental health workers, but play a significant role in identifying at-risk children. Tier two consists of child psychologists, clinical psychiatrists, educational psychologists as well as behavioural teachers. Professionals in this tier work in isolation or as part of a multidisciplinary team. When working in a multidisciplinary team, professionals from tier two now move into tier three to form specialist teams. Tier three consists of family therapy teams such as occupational therapists, behaviour therapists as well as social workers. Although a uni-disciplinary approach may also lead to successful clinical outcomes, a multi-tiered approach is necessary and beneficial when dealing with complex cases (Spender et al., 2016).
Dr Nikki Themistocleous, a Clinical Psychologist and Senior Lecturer at UNISA provided her expert input about the complex procedures involved in diagnosing and treating a child with a mental health issue:
Whether one is treating an adult or a child, it is important for the treating professional to keep in mind the context of their client. Treating individuals in a ‘one size fits all’ manner is problematic and can lead to errors. A psychologist treating children is both a passenger on a bus, as well as the driver, and ones needs to navigate between the two in order to successfully manage a case.
My procedures in treating children involve several factors. The first step is to conduct a comprehensive clinical interview with the parents / legal guardians. This includes obtaining information with regards to the concerns that lead the family to seek treatment (presenting problem), a comprehensive history taking, developmental history and screening for current signs and symptoms of mental illness. I also ensure to obtain information regarding family dynamics and any contextual information that may have led to the development of symptoms. I ask for school reports and any other relevant reports (e.g. previous psychological reports).
Thereafter I usually schedule several sessions with the child. This is to ensure that I assess and observe the child independently from the parents. Once I have developed a hypothesis, I usually, when necessary, obtain some collateral information from school teachers, GPs or any other relevant individual who has been, or is involved in the child’s life. Obtaining information from several sources is vital in developing an accurate clinical picture, which will inform your diagnosis and naturally the treatment plan.
Once I have collected enough information and have formulated hypotheses around the presenting complaint and possible diagnoses, I meet with the parents again to inform them of these. This is where the psychologist as “passenger” is important because the parents are the gatekeepers to treating a child. If they do not feel involved, or safe through this process, treating the child will become an impossible task. I usually spend time explaining to the parents what my findings are, and what my proposed treatment plan is. If needed, this is when I suggest other professionals be included in the treatment plan, for example occupational therapists, psychiatrists, etc.
Mental illness in children is not an easy task as there are many factors to take into consideration, for example family dynamics, developmental stages and the comorbidity of mental illness. Thus, it is vital to ensure that a comprehensive investigation is conducted to ensure bias and misdiagnosis is curbed.
In 2003 the World Health Organization highlighted lack of resources as being one of the key barriers to effective treatment of child mental health (World Health Organization, 2003). In accordance with the WHO, Dr Themistocleous provided the following response to the effectiveness of working in a multi-disciplinary team in the South Africa context:
Context is important, and due to our diverse population and dynamics in the country, operating in a silo will be counterproductive. However, not all clients have access to, or the means to have several professionals involved. Whether this be in a private or public setting, developing the best treatment plan per individual case can be challenging. Contracting a team is expensive in the private context. Furthermore, in the public mental health sectors, not all resources and services are available.
This article highlights the key role psychologists play in multi-disciplinary teams in diagnosis and treatment of child mental health, however each case is unique. Although a multi-disciplinary approach might not always be feasible, considering the lack of resources, demographics complexities, and socio-economic challenges individuals face to access mental healthcare in South Africa, it provides the most comprehensive means to deliver the best possible care to at-risk children and adolescents.
American Psychological Association. (2018). Children’s Mental Health Awareness Day: May 10. Retrieved from http://www.apa.org/pi/families/children-awareness-day.aspx
Dogra, N., Parkin, A., Warner-Gale, F., & Frake, C. (2017). A multidisciplinary handbook of child and adolescent mental health for front-line professionals. Jessica Kingsley Publishers.
Flisher, A. J., Dawes, A., Kafaar, Z., Lund, C., Sorsdahl, K., Myers, B., Thom, R., & Seedat, S. (2012). Child and adolescent mental health in South Africa. Journal of Child & Adolescent Mental Health, 24(2), 149–161. doi:10.2989/17280583.2012.735505
Pride Surveys. (2017, April 20). National Children’s Mental Health Awareness Week. Retrieved from https://www.pridesurveys.com/index.php/blog/national-childrens-mental-health-awareness-week/#_ftn2
RSA (Republic of South Africa) Department of Health. (2003). Policy Guidelines: Child and Adolescent Mental Health. Pretoria: Government Printer.
Skeen, S., Macedo, A., Tomlinson, M., Hensels, I. S., & Sherr, L. (2016). Exposure to violence and psychological well-being over time in children affected by HIV/AIDS in South Africa and Malawi. AIDS Care, 28, 16–25. doi:10.1080/09540121.2016.1146219
Spender, Q., Salt, N., Dawkins, J., Kendrick, T., & Hill, P. (2016). Primary child and adolescent mental health: A practical guide (2nd ed.). CRC Press, New York.
Stancheva, V. (2018). Mental health in children: Children and adolescents living with chronic medical illness. Retrieved from http://www.dgmc.co.za/chronic-medical-illness
World Health Organization. (2003). Investing in mental health. Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva. 2004).