Manasi Kumar, PhD, CPsychol.

Senior Lecturer, Department of Psychiatry

University of Nairobi First Annual Conference on Child

Behavioral Health in Sub-Saharan Africa 12-13th July 2016 Kampala, Uganda

Remit of the panel discussion• What are the pressing child mental health challenges within

specific countries? • What is the current child and adolescent mental health

services infrastructure in each of the three countries? • What are the competing issues children, adolescents and

families face (e.g. poverty, HIV, conflict, interpersonal violence, trauma, lack of economic opportunities) that impact child behavioral health?

• How can stigma be effectively addressed within specific country contexts?

• What role can professionals, community, cultural and religious leaders play in creating effective approaches to child behavioral health?

Key Facts on Child Health• land area of 580,000 km2

population of over 43 million with a life expectancy of 59 years• under 5 - 5.9 million children died in 2015

in SSA. Kenya is ranked no 39 globally in under 5 deaths. About 45% of all child deaths are linked to malnutrition.

• Children in sub-Saharan Africa are greater than 14 times more likely to die before the age of 5 than children in developed regions

• Infectious diseases with neuropsychiatric sequelae such as malaria and HIV/AIDS are more prevalent than elsewhere in the world (Global Burden of Disease Study, 2015) including greater burden of neuropsychiatric deficits associated with epilepsy

Source: Commonwealth secretariat of Kenya(Phillips Owen et al (2016)Child and adolescent mental health in sub-Saharan Africa: a perspective from clinicians and researchers BrJPsych International)

Rise in NMS disorders in late childhood and adolescence

Disability-adjusted life years (DALYs) for each neurological, mental health and substance-use (NMS) disorder in 2010 by age. Davidson et al (2015).

Nature 527, S161–S166 (19 November 2015) doi:10.1038/nature16030

Key Facts in Child Behavioral Health

• In LMICs, estimated one in 7 children and adolescents have significant difficulties, with 1 in 10 (9.5%) having a specific psychiatric disorder (LMIC wide study)

Arch Pediatr Adolesc Med. 2012;166(3):276-281. doi:10.1001/archpediatrics.2011.592.

• While diagnostic psychiatric interviews are necessary for meaningful research, few or no diagnostic interviews have been validated in an African context, particularly among the expanding poorer sections of society

• Multiple languages within a single region can sometimes act as a barrier for behavioral health assessment

Risk and Protective Factors for Poor Behavioral Health

• Clear socio-demographic correlates of psychopathology that place children in areas of greatest deprivation at greatest risk (Cortina et al 2012 –A systematic review in SSA )

• Adverse social circumstances such as war trauma, child abuse and neglect, being orphaned, food insecurity and poverty are significant risk factors

• Protective factors such as parental sensitivity and positive parenting, support from extended family, siblings, and teachers etc haven’t been adequately studied

Parenting & Child Behavioral Health Research in LMICs focusing on Kenya

• Child Behavioral Health Research Focuses in LMICs– Social Determinants of Parenting – Pregnancy, poverty and parenting– Maternal-Child Mental health– Ethnic conflict and child development

Poverty and Related Social Determinants for Poor Parenting: Kenyan evidence

• Adolescents from lower SES have higher attachment and emotional & conduct difficulties than those from middle to high SES. It was also seen that their attachment style is more of avoidance than anxious style (Wambua et al 2015) N=137 VASQ and SDQ.

• Absence of sensitivity of parenting (main aspects of sensitivity were associated with disciplinary methods and child’s access to education), child’ birth order and greater responsibility accorded to the firstborn girl child, parental emotional unavailability, and severity of inter-parental conflicts and child’s level of exposure to it predicted insecurity of attachment to parents (Polkonikova-Wamoto et al. 2016) 8-15 years, N=20

Maternal Depression & Child Well Being

• Depressed mothers were 7 times more likely to not engage in exclusive breastfeeding and were 4 times more likely to have babies who were underweight (Madeghe et al 2016) infant age 0-6months

• Fear of contagion (AOR= 17.91 [1.01 - 39.06] p<0.05) and Negative Self perceived stigma (AOR= 5.59,95% CI[2.59-12.65],P<0.05) highest in depressed women attending PMTCT (Obadia et al 2016) –one can imagine the impact on parenting

• Low infant birth weight was 2.24 times more among the women with depression (Mochache et al. 2016,)

• Intimate Partner Abuse the most frequently found reason behind depression and child neglect aside from abandonment by partner/loss of income by woman (MCMH group)

• Depressed mothers were likely to have Stunted children than non Depressed mothers (N=148). SC scored poorly on KABC fluid intelligence tests than non stunted children. (M of NSC was 69.17 compared to 50.71 for SC (Mbelenga, et al. 2015)

• In a study by Githara et al (2016) on depression and stigma in caregivers of children with intellectual impairments, it was found that those divorced or separated caregivers faced increased unfair treatment compared to single caregivers (OR: 7.84 [2.79 –118.38], p – value = <0.0001) and there is reduced ability to overcome stigma as levels of depression increase.

Maternal Depression….

Ethnic conflict & Child Behavioral Health

• Children who experienced 2007/2008 post-election violence had a high level of PTSD 75.45%. Findings showed that there are tremendous differences in traumatic experiences between children in the violence ridden areas and those in areas which did not witness violence and that there is a significant difference in the level of PTSD between pupils who experienced communal violence and those who did not (Muola, 2013)

• I have worked on attachment trauma post witnessing of violence in children and adolescents. Families and interpersonal relationships are affected in the way violence touches lives of people

Child Behavioral Health Research Gaps In Kenya

• Lack of research using community samples or school age children

• Lack of child behavioral health research– Prevalence research – Psychopathology/risk mechanism testing research – Parenting and child development research

• Lack of evidence-based maternal and child mental health or implementation research

Ongoing Research In Attempts to Address the Child Behavioral

Health Research Gaps(Kumar, et al., 2015-)

Kenya Families from Two CommunitiesResearch Evidence (Kumar et al, 2015)

• N=437 (91% mother, 3% father, 6% other)• Child Characteristics

– 51% girls & 49% boys – Age range 1-13; 17% (n=74) under 3 years old; 63%

(n=276) 3-8 years old; and 20% (n=87) above 9 years old• Family Characteristics/Risks

– 62% food insecure – 27% unemployed– 34% parents had primary or less education– 33% parents had moderate to severe depression– On average, families have 2.71 (SD=1.28) children– 68% married (32% single)

Child Behavioral Health

• Problem Behavior Prevalence– CBCL Validation (Kiswahili version)– Using the developers’ norm sample, we found 19% of

Kenya children were at-risk (above 84 percentile) for INT problem (T >=60) and 11% were at-risk for EXT problem (measured by CBCL).

– For clinical-level problem (above 98 percentile, or T score >=70): 6% Kenyan children had INT problems and 3% had EXT problems

– No child age group(under 3, 3-8, and 9-13 years old groups) or gender group differences on problem behavior prevalence

Psychopathology for Poor Child Behavioral Health

Stress Contexts & Parenting

Parenting & Child Behavioral Health