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Integrating Child & Adolescent Mental Health into the ... - Cittadinanza

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<strong>Integrating</strong> <strong>Child</strong> & <strong>Adolescent</strong><strong>Mental</strong> <strong>Health</strong> <strong>into</strong> <strong>the</strong>General <strong>Health</strong> Care SystemOpen DiscussionOLAYINKA OMIGBODUN, MPH, FMCPsych, FWACPAssociate Professor of PsychiatryCollege of Medicine, University of Ibadan &Consultant in <strong>Child</strong> & <strong>Adolescent</strong> PsychiatryUniversity College HospitalIbadan, Nigeria


Conversation with a NeurosurgeonColleague & Management Executive of aTeaching Hospital• “Dr. Omigbodun where are you coming from?” my colleagueasked.• “I I have just finished running <strong>the</strong> child psychiatric clinic”, , I repliedhoping to hear a well done and happy for an opportunityto ask for more staff and help.• “Honestly any child who needs to see you must need deliverance fromdemons” was <strong>the</strong> ‘commendation’ I got from a fellowcolleague in <strong>the</strong> neurosciences.


WHAT TACTICS ARE NEEDED?Tie up stringsLinkagePhysical<strong>Health</strong>Care<strong>Mental</strong><strong>Health</strong>Untie stringsStigmaDivision


OBJECTIVES1. Define key words2. Describe <strong>the</strong> prevalence & pattern of child mentalhealth problems at different settings of care in LowIncome Countries:– Community– Primary Care– Especially Difficult Situations


POSSIBLE ISSUES FOR DISCUSSION1. Related psychosocial issues of children in <strong>the</strong>sesettings of care2. Appraise and analyse problems with available CAMHservices and difficulties with integration3. Conflicts in legislation pertaining to <strong>Child</strong> <strong>Mental</strong><strong>Health</strong>4. Examples of models/integrated care5. Proffer solutions to providing a coordinated CAMHservice in <strong>the</strong> general health care system


KEY WORDS• Integrate• <strong>Child</strong> & <strong>Adolescent</strong>• <strong>Mental</strong> <strong>Health</strong>• General <strong>Health</strong> Care


CHILD & ADOLESCENT<strong>Child</strong>: up to 17 years<strong>Adolescent</strong>: 10 to 19years


<strong>Mental</strong> <strong>Health</strong>• <strong>Health</strong> according to WHO• <strong>Health</strong> is a state of complete physical, mentaland social well being and not merely <strong>the</strong> absenceof disease or infirmity• <strong>Health</strong> is more than <strong>the</strong> absence of disease• This can now be applied to mental health


<strong>Mental</strong> <strong>Health</strong>• Optimal development & use of mental abilities(thinking, reasoning, understanding, feeling,behaviour)• Successful performance of mental functions interms of thought, mood & behaviour• Results in productive activities, fulfillingrelationships, ability to adapt to change & copewith adversity• <strong>Mental</strong> health is positive & everyone needs itSadock and Sadock, 2007


<strong>Mental</strong> Illness or Disorders• Illnesses with psychological or behaviouralmanifestations• Abnormalities• Emotions• Thoughts• Cognitive functions• Sensory perceptions• Beliefs• Behaviour


Defining <strong>Child</strong> &<strong>Adolescent</strong> <strong>Mental</strong><strong>Health</strong><strong>Child</strong> and adolescent mental health include <strong>the</strong>following (WHO, 2005):• A sense of identity and self worth• Sound family and peer relationships• An ability to be productive and to learn• Capacity to use developmental challenges andcultural resources to maximise development


Defining <strong>Child</strong> &<strong>Adolescent</strong> <strong>Mental</strong><strong>Health</strong><strong>Mental</strong> health in childhood is needed for:• Optimal psychological development• Productive social relationships• Effective learning• An ability to care for self• Good physical health• Effective economic participation as adults


Every <strong>Child</strong> Needs <strong>Mental</strong> <strong>Health</strong>• Promotion of mental health• Prevention of mental illness• Treatment of mental illness• Rehabilitation of <strong>the</strong> mentally ill


General <strong>Health</strong> Care• Service providing holistic care• Comprehensive continuous form of care• Bio-psychopsycho-social social model of disease• Depending on <strong>the</strong> service arrangement– Primary or secondary care– Different cadres of staff depending on country &region– PHC (public & private)– School health– District hospitals


NigeriaTiers of <strong>Health</strong>care Delivery ServiceTertiary <strong>Health</strong>care (Psychiatrists)(Teaching & Specialist Hospitals)Federal GovernmentSecondary <strong>Health</strong>careDistrict Hospitals (Paediatricians)State Governments<strong>Health</strong> Care (PHC) (Nurses, Community <strong>Health</strong>Officers) DistrictsWho will link up services in <strong>the</strong>se levels of care?Who will link up services in <strong>the</strong>se levels of care?FMOH, 1996


<strong>Child</strong> Psychiatric Service in <strong>the</strong> UK(Department Of <strong>Health</strong> , 2004)CAMHS FrameworkTier 4: Essential tertiary level services such as day units, highlyhlyspecialised out-patient teams and in-patient units.Tier 3: A specialised multi-disciplinary service formore severe, complex or persistent disordersTier 2: A level of service provided by uni-professionalgroups which relate to each o<strong>the</strong>r through a network ra<strong>the</strong>rthan a team (Primary mental health workers)Tier 1: A primary level of care (Teachers, health visitors, generalpractitioners, social workers, voluntary workers)


• How do we view child and adolescentmental health?– Positive– Negative– Problems– Disorders– For all children & adolescents


• What are our views & perspectives onGeneral <strong>Health</strong> Care?– Primary level– Secondary level– Varied levels


Why Integrate CAMH in General<strong>Health</strong> Care system• Declining mortality in resource poor settings• Largely youthful populations• <strong>Child</strong> rights• General health workers see most children withmental health disorders• Large proportions of our population live in verydifficult circumstances


Large Young Population


PROPORTIONS OF THE POPULACE LESSTHAN 15YEARS IN SELECTED AFRICANCOUNTRIES


Country/Region<strong>Mental</strong> <strong>Health</strong> Professionals OverburdenedPopulation(Millions)PsychiatristsEthiopia 72 17 none<strong>Child</strong>PsychiatristsServicesnoneKenya 32.8 45 4 LimitedNigeria 150 150 5 LimitedSA:Nor<strong>the</strong>rnCape &Limpopo6 5 nonenoneTunisia 10 200 15 PresentUgandan 27 27 4 Limited


Magnitude of <strong>Child</strong> <strong>Mental</strong><strong>Health</strong> Problems• Dearth of Large Scale Studies• Used broad groupings


Community StudiesKhartoum, Sudan197 children aged 3-153years from Villagesaround Khartoum, SudanCederblad, 1968


Community StudiesKhartoum, Sudan


Community StudiesIbadan, Nigeria16% of 440 children aged 5-16years 5had severebehaviour disordersJegede & Cederblad, 1990


Community StudiesChinaCommunity Studies of children in China reveal rates of mentalhealth problems averaging about 13%. (Hong et al, 2004)


Community StudiesCalicut District, South India9% of 1403 children aged 8-12years 8in Calicut districtof South India had mental disorders(Hacket et al, 1999)


School StudySao Paulo, BrazilSchool children in Sao Paulo and surrounding ruralareas revealed that 13% had psychiatric disorders(Rohde et al, 2004)


School StudyRural & Urban Southwest Nigeria1 in 5 school going adolescents had suicidal ideationin <strong>the</strong> previous year and 1 in 10 had attempted suicide.Sexual abuse and exposure to violence were main riskfactors (Omigbodun et al, 2008)


Primary CareIndia, Sudan, Philippines, ColumbiaBetween 12% to 29% of children attending PC werefound to have mental disorders (Giel et al, 1981)


Primary CareGuinea BissauDe Jong, 1989


Primary CareIbadan, Nigeria990 children aged 7-147years jointly interviewed withmo<strong>the</strong>rs using DSM111R criteria. One fifth had specificDSMIIR diagnosis (Gureje, Omigbodun, 1994)


Primary CareIbadan, Nigeria


<strong>Child</strong>ren in Especially Difficult Circumstances(CEDC)• Three principal & distinct types(UNICEF, 2005)Street <strong>Child</strong>ren


<strong>Child</strong>ren in Especially Difficult Circumstances(CEDC)? Route to a life on <strong>the</strong> Street?Street childrenBreak links with <strong>the</strong>ir familiesAbandon formal educationStreets to hawk various waresSheer poverty in familiesShift of rural poor to urban areas`


Who are <strong>the</strong>se Street <strong>Child</strong>ren? 13.3%Aged 8 – 18 yearsMale96.7%Female•70% Living on street over 2 years•45% Use Psychoactive Substances•69% Use Alcohol•24% Drug Courier•11% Raped•50% Sex Work


Who are <strong>the</strong>se Street <strong>Child</strong>ren? 2School Problems of Street <strong>Child</strong>ren50%40%46%47%30%27%20%10%0%Refusal Suspension TruancySchooling Status


<strong>Child</strong>ren in Especially Difficult Circumstances(CEDC)Working <strong>Child</strong>ren


<strong>Child</strong>ren in Especially Difficult Circumstances(CEDC)<strong>Child</strong>ren in Institutions


Remand Home 2007 235 children (23 boys 12 girls)88%Criminal codeCare, Protection &abandonedBeyond parentalcontrol3%9%(Omigbodun & Bella, 2007)


Remand Home 2007 4Diagnostic Categories18%17%17%16%14%12%14% 14%11%10%8%6%4%3%6%2%0%ConductdisorderPsychoticillness<strong>Mental</strong>retardationCannabisabuseDepressivedisorderEnuresisEpilepsy(Omigbodun & Bella, , 2007)


<strong>Child</strong>ren in conflict regionsNor<strong>the</strong>rn Uganda, Gulu districtRates of psychiatric disorder (Okello,2007)


<strong>Child</strong> <strong>Mental</strong> <strong>Health</strong> Services UnavailableEnormous Toll ofHuman Suffering<strong>Child</strong> <strong>Mental</strong><strong>Health</strong>ReceivesLow Priorityfrom PolicyMakers<strong>Child</strong><strong>Mental</strong><strong>Health</strong>PolicyUnavailable<strong>Child</strong> <strong>Mental</strong>IllnessUndetected &Untreated inGeneral<strong>Health</strong>FacilitiesCommunityFocus onTraditional& ReligiousCare


<strong>Integrating</strong> CAMH <strong>into</strong> <strong>the</strong>General <strong>Health</strong> SystemEnhancementScopeLinkage<strong>Child</strong>Rights<strong>Child</strong>RearingTrainingPovertyCAMHPolicyPartnerships


THANK YOU


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