Child and adolescent mental health services in Uganda

Introduction Worldwide, one in five children and adolescents suffer from mental health disorders, while facing limited opportunities for treatment and recovery. Growing up, they face multiple challenges that might contribute to the development of mental disorders. Uganda is a developing country with a history of prolonged civil and regional wars associated with child soldiers, large numbers of refugees and internally displaced people due to natural disasters and unrests, and a large infectious disease burden mainly due to acute respiratory tract infections, malaria and HIV/AIDS. Objective This paper aims to examine the current status of child and adolescent mental health services in Uganda. Methodology A scoping review approach was used to select studies on child and adolescent mental health services (CAMHS) in Uganda. A search of MEDLINE, Wiley and PubMed databases was conducted using eligibility criteria. The papers were summarized in tables and then synthesized using the Frameworks for monitoring health systems performance designed by the World Health Organisation (WHO). This was done according to the Preferred Reporting Items for Systematic Review and M-Analyses Extension for Scoping Review (PRISMA-ScR) guidelines. Results Twelve studies were identified; five of them used qualitative methods and focused mostly on the current limitations and strengths of CAMHS in Uganda, while six quantitative studies investigated the effects of new interventions. One study used a mixed-methods approach. In summary, the papers outlined a need for collaboration with the primary health sector and traditional healers to ensure additional human resources, as well as the need to focus on groups such as orphans, HIV/AIDS-affected youth, former child soldiers and refugees. Conclusion Relatively few studies have been conducted on CAMHS in Uganda, and most of those that exist are part of larger studies involving multiple countries. CAMHS in Uganda require improvement and needs to focus especially on vulnerable groups such as orphans, HIV/AIDS-affected youth and former child soldiers.publishedVersio

“I feel good when I drink”—detecting childhood-onset alcohol abuse and dependence in a Ugandan community trial cohort

Background Alcohol, substance use, and mental health disorders constitute major public health issues worldwide, including in low income and lower middle-income countries, and early initiation of use is an important predictor for developing substance use disorders in later life. This study reports on the existence of childhood alcohol abuse and dependence in a sub-study of a trial cohort in Eastern Uganda. Methods The project SeeTheChild—Mental Child Health in Uganda (STC) included a sub-study of the Ugandan site of the study PROMISE SB: Saving Brains in Uganda and Burkina Faso. PROMISE SB was a follow-up study of a trial birth cohort (PROMISE EBF) that estimated the effect that peer counselling for exclusive breast-feeding had on the children’s cognitive functioning and mental health once they reached 5–8 years of age. The STC sub-study (N = 148) used the diagnostic tool MINI-KID to assess mental health conditions in children who scored medium and high (≥ 14) on the Strengths and Difficulties Questionnaire (SDQ) in the PROMISE SB cohort N = (119/148; 80.4%). Another 29/148 (19.6%) were recruited from the PROMISE SB cohort as a comparator with low SDQ scores (< 14). Additionally, the open-ended questions in the diagnostic history were analysed. The MINI-KID comprised diagnostic questions on alcohol abuse and dependence, and descriptive data from the sub-study are presented in this paper. Results A total of 11/148 (7.4%) children scored positive for alcohol abuse and dependence in this study, 10 of whom had high SDQ scores (≥ 14). The 10 children with SDQ-scores ≥ 14 had a variety of mental health comorbidities of which suicidality 3/10 (30.0%) and separation anxiety disorder 5/10 (50.0%) were the most common. The one child with an SDQ score below 14 did not have any comorbidities. Access to homemade brew, carer’s knowledge of the drinking, and difficult household circumstances were issues expressed in the children’s diagnostic histories. Conclusions The discovery of alcohol abuse and dependence among 5–8 year olds in clinical interviews from a community based trial cohort was unexpected, and we recommend continued research and increased awareness of these conditions in this age group. Trial registration Trial registration for PROMISE SB: Saving Brains in Uganda and Burkina Faso: Clinicaltrials.gov (NCT01882335), 20 June 2013. Regrettably, there was a 1 month delay in the registration compared to the commenced re-inclusion in the follow-up study: https://clinicaltrials.gov/ct2/show/NCT01882335?term=saving+brains&draw=2&rank=1publishedVersio

"She gives it to her child who doesn't even talk": a qualitative exploration of alcohol and drug use among primary school-age children in Uganda.

BACKGROUND: There is little research on alcohol and other drugs (AOD) use by school-age children in low-resource settings like Uganda. Including the voices of children in research can inform prevention and early intervention efforts for those at risk of AOD use. The aim of this study was to understand the perspectives of children aged 6 to 13 years regarding AOD in Uganda. METHODS: This qualitative study was conducted in Mbale district, Uganda from February to March 2020. Eight focus group discussions (FGDs) were conducted with 56 primary school-age children, stratified by age (6-9 and 10-13 years), sex (male and female), and school status (in school and out of school). All FGDs were conducted in either Lumasaaba or Luganda. The FGDs were audio-recorded, transcribed verbatim, and translated into English. Data were coded, and overarching themes were identified using thematic framework analysis. RESULTS: Two themes identified were (1) Children's perceptions and experiences with AODs. The participants understood alcohol by its consistency, colour, odour, and by brand/logo. They described the types and quantities of AOD consumed by school-age children, brewing processes for homemade alcoholic drinks, and short and long-term consequences of the use of alcohol. (2) Contributing factors to childhood drinking included: Stress relief for children who experienced multiple adversities (orphaned, poverty-stricken, and hailing from broken homes), fitting in with friends, influence from families, and media exposure that made alcohol look cool. Children would start drinking at an early age) or were given alcohol by their parents, sometimes before they could start talking. In the community, alcohol and other drugs were cheap and available and children could drink from anywhere, including in the classroom. CONCLUSIONS: Children eligible for primary education in Uganda can easily access and use AOD. Several factors were identified as contributing to alcohol and other drug use among children, including availability and accessibility, advertising, lack of parental awareness and supervision, peer influence, adverse childhood experiences, socioeconomic factors, and cultural norms. There is a need for multi-sectoral action for awareness of childhood AOD use and deliberate consideration of children in the planning, design, and implementation of research, policies, and programs for prevention and early intervention

Child and adolescent mental health services in Uganda

Introduction Worldwide, one in five children and adolescents suffer from mental health disorders, while facing limited opportunities for treatment and recovery. Growing up, they face multiple challenges that might contribute to the development of mental disorders. Uganda is a developing country with a history of prolonged civil and regional wars associated with child soldiers, large numbers of refugees and internally displaced people due to natural disasters and unrests, and a large infectious disease burden mainly due to acute respiratory tract infections, malaria and HIV/AIDS. Objective This paper aims to examine the current status of child and adolescent mental health services in Uganda. Methodology A scoping review approach was used to select studies on child and adolescent mental health services (CAMHS) in Uganda. A search of MEDLINE, Wiley and PubMed databases was conducted using eligibility criteria. The papers were summarized in tables and then synthesized using the Frameworks for monitoring health systems performance designed by the World Health Organisation (WHO). This was done according to the Preferred Reporting Items for Systematic Review and M-Analyses Extension for Scoping Review (PRISMA-ScR) guidelines. Results Twelve studies were identified; five of them used qualitative methods and focused mostly on the current limitations and strengths of CAMHS in Uganda, while six quantitative studies investigated the effects of new interventions. One study used a mixed-methods approach. In summary, the papers outlined a need for collaboration with the primary health sector and traditional healers to ensure additional human resources, as well as the need to focus on groups such as orphans, HIV/AIDS-affected youth, former child soldiers and refugees. Conclusion Relatively few studies have been conducted on CAMHS in Uganda, and most of those that exist are part of larger studies involving multiple countries. CAMHS in Uganda require improvement and needs to focus especially on vulnerable groups such as orphans, HIV/AIDS-affected youth and former child soldiers

Health managers’ views on the status of national and decentralized health systems for child and adolescent mental health in Uganda: a qualitative study

Background: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15–30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. Methods: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. Results: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. Conclusion: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent

Does mhGAP training of primary health care providers improve the identification of child- and adolescent mental, neurological or substance use disorders? Results from a randomized controlled trial in Uganda

Background. Integrating child and adolescent mental health (CAMH) into primary health care (PHC) using the WHO mental health gap action program (mhGAP) is recommended for closing a mental health treatment gap in low- and middle- income countries, but PHC providers have limited ability to detect CAMH disorders.We aimed to evaluate the effect of PHC provider mhGAP training on CAMH disorder identification in Eastern Uganda. Methods. Thirty-six PHC clinics participated in a randomized controlled trial which compared the proportion of intervention (n = 18) to control (n = 18) clinics with a non-epilepsy CAMH diagnosis over 3 consecutive months following mhGAP-oriented CAMH training. Fisher’s exact test and logistic regression based on intention to treat principles were applied. (clinicaltrials.gov registration NCT02552056). Results. Nearly two thirds (63.8%, 23/36) of all clinics identified and recorded at least one non-epilepsy CAMH diagnosis from 40 692 clinic visits of patients aged 1–18 recorded over 4 months. The proportion of clinics with a non-epilepsy CAMH diagnosis prior to training was 27.7% (10/36, similar between study arms). Training did not significantly improve intervention clinics’ non-epilepsy CAMH diagnosis (13/18, 72.2%) relative to the control (7/18, 38.9%) arm, p = 0.092. The odds of identifying and recording a non-epilepsy CAMH diagnosis were 2.5 times higher in the intervention than control arms at the end of 3 months of follow-up [adj.OR 2.48; 95% CI (1.31–4.68); p = 0.005]. Conclusion. In this setting, mhGAP CAMH training of PHC providers increases PHC clinics’ identification and reporting of non-epilepsy CAMH cases but this increase did not reach statistical significance

Child mental illness and the help-seeking process: a qualitative study among parents in a Ugandan community

Abstract Background: Child mental illness contributes signifcantly to the burden of disease worldwide, and many are left untreated due to factors on both the provider and user side. Recognising this, the Ugandan Ministry of Health recently released the Child and Adolescent Mental Health (CAMH) Policy Guidelines. However, for implementation to be successful the suggested policy changes must resonate with the service users. To better understand the sociocultural factors infuencing parental mental help-seeking, we sought insights from parents in the Mbale district of eastern Uganda. Method: In this qualitative study, eight focus group discussions were conducted with mothers and fathers in urban and rural communities. Parents of children younger than 10 years were purposively selected to discuss a vignette story about a child with symptoms of depression or ADHD as well as general themes relating to child mental illness. The data were analysed using qualitative content analysis. Results: Descriptions of severe symptoms and epileptic seizures were emphasised when recognising problem behaviour as mental illness, as opposed to mere ‘stubbornness’ or challenging behaviour. A mixture of supernatural, biomedical, and environmental understandings as underlying causes was refected in the help-seeking process, and diferent treatment providers and relevant institutions, such as schools, were contacted simultaneously. A notion of weakened community social support structures hampered access to care. Conclusion: Awareness of symptoms closer to normal behaviour must be increased in order to improve the recognition of common mental illnesses in children. Stakeholders should capitalise on the common recognition of the importance of the school when planning the upscaling of and improved access to services. Multifactorial beliefs within the spiritual and biomedical realms about the causes of mental illness lead to multisectoral help-seeking, albeit without collaboration between the various disciplines. The CAMH Policy Guidelines do not address traditional service providers or provide a strategy for better integration of services, which might mean continued fragmentation and inefective service provision of child mental health care

Prevalence and associated factors of attention deficit hyperactivity disorder (ADHD) among Ugandan children; a cross-sectional study

Abstract Background Attention deficit hyperactivity disorder (ADHD) is a common neuropsychiatric disorder among the children. The burden of ADHD or its associated factors in Uganda are not known. The objective of this study was to determine the prevalence and the associated factors of ADHD among children attending the neurology and psychiatry clinics at Mulago National Referral Hospital. Methods Using the disruptive behavior scale (45 items), we investigated the presence of ADHD symptoms among children attending Mulago Hospital. Questionnaires were administered to the primary care-takers of the study participants to gather information on the factors associated with ADHD. All children were subject to a clinical examination. Children presumed to have ADHD, using the aforementioned rating scale were further assessed by a child psychiatrist to confirm the diagnosis and associated co-morbid conditions. Results The estimated prevalence of DSM-IV ADHD symptoms was 11%. Children aged less than 10 years were four times likely to have ADHD (OR 4.1, 95% CI 1.7–9.6, p < 0.001). The demographic factors independently associated with ADHD were age less than 10 years, male gender, history of maternal abnormal vaginal discharge during pregnancy, and no formal education or the highest level of education being primary school. Conclusion The prevalence of ADHD among children attending the pediatric neurology and psychiatry clinics is high in our settings and is associated with delayed milestones. Early identification and addressing the co-morbid conditions associated with ADHD such as epilepsy, autism spectrum of disorder, conduct disorder, opposition defiant disorder and intellectual disability in our setting is needed

Are we overlooking alcohol use by younger children?

Alcohol use is a leading contributor to the burden of disease among youth. Early-onset use is associated with later life dependency, ill health and poor social functioning. Yet, research on and treatment opportunities for alcohol use among younger children are scarce. Despite knowledge that alcohol intake occurs in childhood, and the fact that children understand alcohol related norms and develop alcohol expectancies from age 4, younger children are rarely included in studies on alcohol use.Patterns of early alcohol use vary greatly across the globe and are part of complex interplays between sociocultural, economic and health-related factors. Family influence has proven important, but genetic factors do not seem to play a crucial role at this age. Stressful circumstances, including mental health problems and sociocultural factors can entice alcohol use to cope with difficult situations. The World Health Organization has developed guidelines for effective strategies to reduce the harmful use of alcohol, including preventative and treatment interventions, but important gaps in implementation remain. An increased focus on research, policy and implementation strategies related to early alcohol use is warranted, granted its wide-ranging implications for public health and social functioning. In this summary of literature on alcohol use among younger children and adolescents, we show that younger children (aged 10 and younger) tend to be systematically overlooked. However, research, interventions and policy implementation strategies need to include younger children to mitigate the global burden of harmful alcohol use more effectively.publishedVersio

“I feel good when I drink”—detecting childhood-onset alcohol abuse and dependence in a Ugandan community trial cohort

Background Alcohol, substance use, and mental health disorders constitute major public health issues worldwide, including in low income and lower middle-income countries, and early initiation of use is an important predictor for developing substance use disorders in later life. This study reports on the existence of childhood alcohol abuse and dependence in a sub-study of a trial cohort in Eastern Uganda. Methods The project SeeTheChild—Mental Child Health in Uganda (STC) included a sub-study of the Ugandan site of the study PROMISE SB: Saving Brains in Uganda and Burkina Faso. PROMISE SB was a follow-up study of a trial birth cohort (PROMISE EBF) that estimated the effect that peer counselling for exclusive breast-feeding had on the children’s cognitive functioning and mental health once they reached 5–8 years of age. The STC sub-study (N = 148) used the diagnostic tool MINI-KID to assess mental health conditions in children who scored medium and high (≥ 14) on the Strengths and Difficulties Questionnaire (SDQ) in the PROMISE SB cohort N = (119/148; 80.4%). Another 29/148 (19.6%) were recruited from the PROMISE SB cohort as a comparator with low SDQ scores (< 14). Additionally, the open-ended questions in the diagnostic history were analysed. The MINI-KID comprised diagnostic questions on alcohol abuse and dependence, and descriptive data from the sub-study are presented in this paper. Results A total of 11/148 (7.4%) children scored positive for alcohol abuse and dependence in this study, 10 of whom had high SDQ scores (≥ 14). The 10 children with SDQ-scores ≥ 14 had a variety of mental health comorbidities of which suicidality 3/10 (30.0%) and separation anxiety disorder 5/10 (50.0%) were the most common. The one child with an SDQ score below 14 did not have any comorbidities. Access to homemade brew, carer’s knowledge of the drinking, and difficult household circumstances were issues expressed in the children’s diagnostic histories. Conclusions The discovery of alcohol abuse and dependence among 5–8 year olds in clinical interviews from a community based trial cohort was unexpected, and we recommend continued research and increased awareness of these conditions in this age group. Trial registration Trial registration for PROMISE SB: Saving Brains in Uganda and Burkina Faso: Clinicaltrials.gov (NCT01882335), 20 June 2013. Regrettably, there was a 1 month delay in the registration compared to the commenced re-inclusion in the follow-up study: https://clinicaltrials.gov/ct2/show/NCT01882335?term=saving+brains&draw=2&rank=