Earlier this year, the annual South African Child Gauge indicated that child and adolescent mental health services in South Africa are in crisis - mostly due to inadequate resources for mental health services, especially for young people.
Meanwhile, during an event on World Mental Health Day, deputy director-general in the National Department of Health Dr Nicholas Crisp used the word "frightening" to describe the very low numbers of people actually receiving the mental healthcare services they need. Despite data showing that the government spends about 5% of the country's total health budget on mental health, these services only reach about one in ten people who need mental health support.
The Child Gauge highlighted that even with the best possible mental health promotion and prevention strategies, approximately 10% to 20% of children and adolescents will develop a mental disorder and/or a neurodevelopmental disability. According to the clinical programme coordinator in the Khayelitsha Eastern Substructure (KESS) in Cape Town, Dr Stella Mokitimi, it is often difficult for children and adolescents struggling with mental health, to get the help that they need at the right time. They often have to share already limited resources with adults and sometimes be exposed to adult behaviour that can further impact their mental health.
Studies suggest that 50% to 80% of all adult mental health disorders emerge before the age of 18, which makes early intervention for children and adolescents crucial. But an article co-authored by Mokitimi states that fewer than 10% of children and adolescents in the Western Cape, for example, who need diagnosis and treatment for a mental disorder, actually receive it.
Importance of child-friendly services
Ideally, children and adolescents should have access to mental health services which range from health promotion to preventative, curative, and rehabilitative services but amid resource constraints, these services are not always available.
According to Mokitimi, dedicated child and adolescent mental health services are important because they reduce the psychological trauma that can result from treating adults and children with mental health issues together.
"Mixing adolescents and adults who are mentally disturbed can expose adolescents to undesirable and inappropriate adult behaviours. Dedicated child and adolescent mental health services may improve the safety of this vulnerable population group," she tells Spotlight.
The Khayelitsha pilot
The Gauge singled out a pilot project in the Khayelitsha Eastern Substructure in Cape Town, where child and adolescent-centric mental health services are provided in clinics in Khayelitsha.
There are nine clinics servicing public healthcare users in the Eastern substructure, including among others, Mfuleni, Michael Mapongwane, Kleinvlei, and Macassar Clinics. As part of the pilot, Mokitimi says, these clinics have all made provision in their facilities to have a dedicated room or section of a room for a child's mental health assessment - offering a dedicated day and space to assess children and adolescents with mental health challenges.
For now, each clinic has one or two nurses dedicated to providing mental health services for kids and adults, depending on the caseload. However, Mokitimi says, by the look of things they will have to increase the number of nurses and they are closely monitoring the caseload, which is showing an increase. She says they don't yet know what is behind the increase.
To beef up the number of nurses who can provide mental health support, they have opened up training to all nurses working in the KESS clinics.
Mokitimi says the substructure has an estimated population of 1.2 million, and children and adolescents (under 19 years) make up 33% (397 294) of the population. The data from the second quarter of this year (July to September), she says, show that in that period, there were 1 482 children younger than 19 who presented at their facilities for specialist mental health services.
"There is also a cohort that is seen at paediatric services and also treated at general health services that are not counted in this 0.4%. [Some] groups receive preventative services from non-profit organisations. However, this shows that we still have a treatment gap of more than 90%," says Mokitimi.
Noting some positive changes, Mokitimi says the shift to having a dedicated space and a day to serve children and adolescents is working very well so far.
"We are seeing a rise in the numbers of children and adolescents who are seen in these facilities. From the first quarter of 2022 to the second quarter of 2022, the numbers have risen by 8% across our facilities at KESS. These numbers, especially at some clinics, will soon require more than just a day allocated to children and adolescents," says Mokitimi.
"I have also observed an increased enthusiasm from the facility managers and mental health nurses providing responsive services. Some clinics took the initiative and made provision for the assessment tools even before the substructure could provide them - heeding the call to make the spaces child-friendly. The attitude towards children and adolescents with mental health problems is shifting very positively," says Mokitimi. "We are not yet where we want to be but we are taking the right steps in the right direction."
Making changes
When Spotlight visited the Michael Mapongwane Community Health Centre in November, we were shown a room that was previously used for adherence clubs for people living with chronic conditions that had been turned into a space where children and adolescents can be assessed for mental health challenges.
Though the room is still a work in progress, it is functional. In the middle of the room, there is a small chair and a table with eye-catching child-friendly items, including play dough, miniature soldiers, and playing cards. During Spotlight's visit, one of the mental health nurses was playing with and talking to a child seated at the table.
Mokitimi says that this is part of their efforts to build friendly services for children and adolescents. "For all our nine clinics in the substructure, this (the table) is the assessment tool. This is what the table should look like in all our clinics, ideally."
"With these assessment tools children are able to express themselves through play and as a clinician you are able to pick up if a child has a mental health challenge," she says. "Children don't just play. Children always act or repeat what they have heard or seen. Often through play, they can express their fears, desires, and challenges. That is why we are making it a point that our health facilities to have a safe space for our children to play and be assessed."
Mokitimi says in their substructure they have increased the training for community mental health nurses vigorously this year.
"We have made it a point that on Fridays all our nurses attend workshops, training, or conferences to better equip them to deal with mental health services. This training is not only for mental health nurses but all the nurses at the clinics because they are a point of contact when someone comes to the clinic, so they must be able to pick up if there is a need for mental health services," she says.
'haven't provided the best'
One of the mental health nurses, Nombulelo Nomayela, says she didn't realise how mixing adults and children can be traumatic for them.
"It is only now that I realised that for years, we haven't provided the best for our children, given the set-up we have. We thought what we were doing was enough, but what we didn't realise is that we put the lives of our children at risk. They didn't have a safe space where they could share exactly how they are feeling. We treated them like adults," she says.
Now, she says, they take time with each child.
At Michael Mapongwane clinic, they have dedicated Thursdays to providing services only for children. Adults are seen on other days. On Thursdays, the number of children they see varies with an average of ten.
"What we do is we separate follow-ups and new cases," says Nomayela. "New cases take time. A nurse can sit with one child for an hour and a half or more so that we get as much information as we can. Follow-up cases don't take so much time. We also book appointments based on who goes to school and who doesn't and we try and prioritise those going to school or writing exams."
Another nurse, Khayakazi Mgaleli says the assessment tool is much needed. "It is not always easy to engage with children and for them to explain what they are going through, but with the toys in front of them it will be much easier," she says.
Sign up for free AllAfrica Newsletters
Get the latest in African news delivered straight to your inbox
Mgaleli says it is more about building a relationship and helping them to open up. "As a mental health nurse, you have to understand the children's language. You have to listen carefully. Children are so vulnerable and before they talk to you, they just want to know and feel if they can trust you. For most of them before they even start talking to you, they will ask you if you will tell their parents, so the tool makes things easier," she says.
Service welcomed
A mother of three from Makhaza has been taking her nine-year-old daughter to the clinic for the past four years. "It has been an unpleasant experience. It didn't matter what you came for, you had to arrive in the morning and wait hours to be attended to," she says.
"I'm really happy that kids now have their own day. There has been a huge improvement. I must say we are really grateful that they have separated the adults from the kids. You know it was so scary because mental health challenges for children and adults are not the same. Adults talk to themselves, act differently, and at times they can be physical and our children had to see all that and it made them scared. My child didn't want to come to the clinic anymore," she says.
"What makes this change work is the fact that when you get to this room, the child goes straight to the table and finds so many things to play with. This also allows parents to talk to the nurse properly and share all the information."
Not impossible
Mokitimi hopes that soon this will also make a difference to other families across clinics. She says what they have done in the Khayelitsha Eastern Substructure can be done in other areas. This is why they always invite staff from other substructures to join their training sessions.
"There are so many variables, but it is not impossible. This can be done. We don't need a lot of space - just a corner in a room designed nicely can help these children a lot," she says.
