Background
Recent years have seen an increasing awareness of the impact of child mental health problems on the global burden of disease [
1‐
3]. This is particularly true for low and middle income countries (LMICs), where children and adolescents constitute a high proportion of the overall population [
2]. Children in low-resource settings are often disproportionally affected by risk factors such as violence, poverty, malnutrition and ill-health. Exposure to these multiple and often cumulative risks can have lasting effects on their development, mental health and psychosocial wellbeing, including a higher life-long risk of mental health problems [
4‐
6]. Despite the vast needs in LMICs, child and adolescent mental health care is an often neglected area [
1‐
3,
7]. In humanitarian settings, which disproportionately affect LMICs, mental health and psychosocial support programs are becoming a standard part of humanitarian interventions, but there remains a large gap between popular interventions and knowledge on effective practices [
8].
In this study we examine the particular situation of child and adolescent mental health (CAMH) care in the post-conflict setting of Sierra Leone. The study was undertaken before the ebola virus disease (EVD) Outbreak of 2014/2015 and the situation on the ground will have changed in some respects. Nonetheless, we believe the findings of this study are important to take into account both for the longer term EVD outbreak response and continued attention to long-term mental health consequences of the conflict.
Situated on the west coast of Africa, Sierra Leone is bordered on the north by Guinea and on the south by Liberia. Its estimated population is approximately 6 million [
9]. Sierra Leone gained its independence from Britain in 1961. From 1991 to 2002 the country experienced a brutal armed conflict, which left approximately 70,000 people killed and about half of its population displaced [
10]. Human rights atrocities included the amputation of limbs, and the systematic sexual abuse of women and girls [
11]. Nearly 7000 children are believed to have been recruited as child soldiers [
12]. The conflict severely damaged the country’s infrastructure: health facilities were destroyed and many health professionals fled the country [
13].
The 2010–2015 National Health Sector Strategic Plan of the Government of Sierra Leone paints a rather grim picture of the general maternal and child health status of the country before the EVD outbreak, including high maternal, infant and under-five mortality rates and high incidences of malaria, malnourishment and stunting of growth [
14]. To tackle the many health issues, the President of Sierra Leone launched an ambitious free healthcare initiative in 2010 for pregnant women, breastfeeding mothers and all children younger than 5 years. While the programme resulted in increased healthcare use, it also revealed weak components in the health care system such as a lack of medication, diagnostic services, electricity, running water and transportation [
15]. The EVD outbreak exposed the weak health systems to the outside world [
16]. The epidemic resulted in a major setback in maternal and child health, due to the partial closure of health facilities, fear among the population to use health facilities, and the suspension of vaccination campaigns resulting in the emergence of old diseases such as measles [
17‐
19].
The status of mental health care in Sierra Leone 10 years after the ending of the conflict was described by Shackman and Price [
20]. They point out that at the end of the war, mental health and psychosocial support interventions focused on reconciliation, child soldier reintegration and trauma-related counselling. Many services were provided by international non-governmental organisations (NGOs), most of which left the country after completing their projects. In recent years there has been an increased local interest in the development of mental health care services in Sierra Leone. The Mental Health Coalition of Sierra Leone was initiated in 2011, bringing together national and international stakeholders in mental health [
21]. The Mental Health Policy enacted in 2012 offers a framework for the development of mental health systems in the country [
22]. Belfer identifies the development of CAMH policy as a key to the establishment of child and adolescent mental health care services [
23]. The decision to design an addendum to the Mental Health Policy for Child & Adolescent Mental Health (with corresponding guidelines for delivery of care) in the Mental Health Strategic Plan 2014–2018 [
14] can therefore be seen as a step in the right direction. References made to mental health in other documents recently released by the Government of Sierra Leone [
24,
25] seem to indicate an increased awareness about mental health among law and policy makers. This may pave the way to the development of specific policy for CAMH care in Sierra Leone. At the time of our survey, the country had one retired psychiatrist, one clinical psychologist in private practice and four psychiatric nurses (one expatriate). Degree courses in psychiatry, psychology and mental health social work were unavailable [
26] and there was no specialist training in CAMH. The Mental Health Strategic Plan 2014–2018 outlines strategies for the development or revision of mental health curriculum for all levels of training in health and social work, and mentions CAMH as a specific topic to be included [
27]. In 2012, with help from international donors, the College of Medicine and Allied Health Sciences launched a certificate and diploma course in mental health nursing. Since the completion of our survey, 22 nurses were trained and subsequently employed in district hospitals across the country. Despite these developments, a WHO Consultation Meeting in Freetown in 2015 concluded that the country was not sufficiently prepared to deal with the psychosocial effects of the EVD outbreak and that the international response again tended to focus on short-term solutions rather than on sustainable development of a mental healthcare system [
28].
A concise review of recent (January 2000–October 2015) literature on child mental health in Sierra Leone (see Additional file
1) shows that 26 out of 42 studies are exclusively on children associated with the armed forces [
29‐
54], while another 14 included or exclusively studied the larger population of children affected by the armed conflict [
55‐
68]. The studies include unique longitudinal research of the mental health outcomes of children associated with and/or affected by the war by Betancourt et al. [
29‐
34,
49‐
51,
56,
57,
61‐
66,
69]. There are many valuable lessons to be learned from these studies of child mental health in Sierra Leone in the context of war, which included the linguistic and cultural adaptation of relevant assessment tools, and the development of a promising low-cost intervention to improve youth mental health and (school) functioning in war-affected youth. We identified two studies published on child mental health topics not related to the conflict [
70,
71] and one prevalence study on the mental health and psychosocial needs of children with and without parental support in the eastern part of Sierra Leone [
55]. Five to six years after the conflict, this study found an extremely high prevalence of mental disorders among the children (8–20 years), e.g. Major Depressive Disorder (80 %), PTSD (76.5 %) and conduct disorder (20.2 %). The symptoms experienced by these children severely impaired their social and educational capacities. Although the study has some methodological limitations, its outcomes do highlight the need for research on child and adolescent mental health in Sierra Leone.
The overall aim of this study was to identify potential barriers and opportunities for the development of CAMH care in Sierra Leone. In particular, we were interested in (a) providing an overview of current systems of child mental health care; (b) make a preliminary inventory of local explanations related to child mental health; and (c) explore how these explanations affect help-seeking patterns, and how they relate to stigma.
The WHO proMIND profile on Sierra Leone [
26] identifies stigma as a major issue affecting mental health in Sierra Leone. Brief surveys done by an international NGO showed that most inhabitants of local communities believed mentally ill people to be evil, violent, lazy, stupid, unable to marry or have children, and unfit to vote [
72]. In Sierra Leone society, children hold the lowest social status and their main role is to serve the household and be obedient to fathers and elders in general [
73]. Therefore, behavioural and emotional deviance is likely to be less tolerated in children than in adults. This can result in an even greater stigma affecting children with mental health problems [
74]. Although our study did not have stigma as its main focus, we did find it helpful to look at the many references to stigma in the light of Mukolo’s suggested framework of stigma experience in child mental disorders [
75]. Mukolo’s framework describes the interrelated constructs of (1) dimensions (stereotypes, discrimination and devaluation), (2) context (self, general and public) and (3) targets (child, family/associates and service) of stigma.
Results
CAMH in Mental Health Care Services
By March 2012, the Mental Health Coalition of Sierra Leone had identified 11 MHC Providers, functioning on 13 locations, of which seven were based in Freetown. There were no MHC Providers in the Southern Province. Additionally, two government-supported schools (one in Freetown, one in Bo) provided education for children with intellectual disabilities. Most MHC Providers made use of counsellors for whom they provided in-house training. Interviews and reviews of patient records revealed that the MHC Providers primarily served the adult population. The child and adolescent caseloads of MHC Providers over the year 2011 were low (see Table
2). The majority (84 %) of children were registered with one NGO providing group and individual counselling in the Eastern Province of Sierra Leone.
Table 2
Child and adolescent caseload mental health care providers
| 0–12 male | 0–12 female | 13–17 male | 13–17 female | Total |
1 | West | Outpatient | 0 | 0 | 15 | 14 | 29 |
2 | West | Outpatient | 0 | 2 | 1 | 4 | 7 |
3 | West | Outpatient | No information available |
4 | West | Residential, day carea
| 1 | 0 | 2 | 0 | 3 |
5 | West | Residential | No information available |
6 | West | Daycare | Not yet functioning in 2011 |
7 | West | Outpatient | 0 | 0 | 0 | 0 | 0 |
8 | East | Outpatientb
| 121 | 58 | 52 | 66 | 297 |
9 | East | Outpatientb
|
10 | East | Outpatient | 0 | 0 | 0 | 0 | 0 |
11 | East | Outpatient | 2 | 1 | 1 | 1 | 5 |
12 | North | Outpatient | 1 | 2 | 0 | 1 | 4 |
13 | North | Outpatient | 5 | 3 | 1 | 1 | 10 |
| Total | 130 | 66 | 72 | 87 | 355 |
Seven MHC providers mentioned ‘lack of resources’ as a challenge, which indicates that both the sustainability and coverage of mental health care services, including services for children, remain a challenge. Two projects that were included in this survey (3 and 6 in Table
2) recently ceased their activities.
CAMH in (primary) health care
In response to an open question on observed mental health problems, nurses and doctors most frequently mentioned mental health issues and disabilities as a result of physical illness (cerebral malaria, meningitis) or trauma (accidents resulting in traumatic brain injury). Anecdotal evidence shared by the respondents showed that they were mostly referring to severe mental and neurological disabilities. Very few cases were reported in response to presented DSM-IV categories. One paediatrician pointed out that in the absence of referral mechanisms health care workers tend to ignore mental health related issues. In general, health workers did report specific risk factors for mental health, such as poverty, abuse, changing caregivers, traffic accidents, substance abuse, and teenage pregnancy.
CAMH in schools
Similar to health care providers, teachers reported few mental health problems in their students. A trained counsellor/teacher in a large secondary school estimated that at most about 2 % percent of the children in her school (which mostly caters for less-privileged children with relatively poor academic performance) would benefit from professional mental health care. The secondary school teachers did not report any serious problems with substance abuse in their schools, a result which was questioned by the participants in the feedback meeting. While two out of the four schools had Guidance and Counselling units, three schools reported financial constraints that prevent them from providing extra care for children with special (psychosocial) needs. In the feedback meeting participants commented that Guidance and Counselling Units are usually not very effective as they are poorly financed. According to one participant they were often supported by NGOs and ceased functioning after the NGOs departed.
Identified CAMH problems
MHC Providers commonly did not provide diagnoses in line with psychiatric classification systems or applied terminology in alternative ways. For example, one MHC Provider diagnosed three out of their four child patients (8, 10 and 12 years old) with schizophrenia, which, based on their age, observation by the first author and provided information, seemed not in line with the DSM definition of this concept. Often MHC Providers gave a description of presenting problems rather than a formal diagnosis. In other situations we were not able to access individual patient information but were given group classifications such as “children with behavioural problems.” Table
3 gives a categorised overview of CAMH problems as identified by MHC Providers in their caseloads.
Table 3
CAMH problems as identified by MHC Providers in their caseloads
Developmental disorders | Autism, mental retardation |
Mood disorders | Depression, mania |
Psychotic disorders | (Acute) psychosis, drug-induced psychosis, schizophrenia, mania |
Behavioural problems & substance abuse | Behavioural problem/disorder, substance abuse (cannabis and alcohol), gang activity and membership, addiction to stealing, murder, stubbornness |
Emotional Problems | Anger, low self-esteem, grief, stress, exam-related stress, rebellion, anxiety |
Social Problems | Problems in social interaction |
Family and child rearing issues | Family (relational) problems, rejection, “adolescence crisis” (being misunderstood by parents who do not accept their children are growing up), lack of parenting skills |
Abuse | Emotional abuse, sexual harassment, rape |
Issues related to sexuality | Homosexuality, masturbation, prostitution |
Other | Bitterness, “unforgiveness”, financial problems, career issues, epilepsy |
Most MHC providers treated children and adolescents through individual or group counselling. The two mental health units at local hospitals seemed to mostly depend on pharmaceutical treatment. Out of the fifteen children treated for mental health problems in 2011, eleven received a first-generation antipsychotic and one an anxiolytic. For the remaining three children treatment information was unavailable.
Treatment gap
In the absence of children treated for mental health issues in the (primary) health care system, we only used the number of children registered with MHC Providers as presented in Table
2 to identify the treatment gap for children with mental health problems in 2011. We were aware of one MHC Provider who was not included in the Mental Health Coalition data base in 2012 and therefore not included in the research. Two others were not able to provide information and one was not yet functioning in 2011. Through extrapolation we estimated the total number of children who had access to mental health care as provided by MHC Providers in 2011 to be 377 children. Unicef estimated the number of children (<18 years) in Sierra Leone at 2,965,000 in 2011 [
82]. Prevalence rates obtained from community studies in other resource-poor settings vary from 8 to 16 % [
83]. Based on this we can expect the number of children with mental health problems in Sierra Leone in 2011 to have been 237,200 to 474,400. This reveals an estimated treatment gap of 99.8–99.9 %. This is higher than the estimated 99.5 % treatment gap for the entire population [
26].
Traditional healers
Traditional Healers mostly reported treatment of children with problems related to witchcraft or ‘demonic’ powers. Diagnoses are being made using special, God-given capacities, observation of behaviour or bodily symptoms, and divination techniques using cowry shells, mirrors, leaves, etc. Treatment may include: secret ceremonies to pull the children from the underworld (the realm of demons and witches); herbal concoctions to drink, wash or rub on faces/bodies; establishing rules/regulations that need to be respected (e.g. not taking a bath at certain hours, as there are more demons around at that time of the day); sacrifices to pacify the demons; washing with a locally made soap or “Lasmami” (written Arabic text washed from a slate) as well as advice to parents and children. During our visit with a prominent healer we were able to witness an example of a parent seeking help for her children:
Two children (a boy aged 8 and a girl aged 11 years) are brought in by their mother, as both are believed to have been initiated as witches. The boy’s behaviour is described as “acting like a fool” and being playful in school. In contrast, the girl is described as being “too quiet.” When questioned publicly, both children confirm the charges.
Some healers said that sometimes it has to be accepted that a child does not improve:
“Some are made like that by God. We don’t go against this.” A female healer explained how in that case care should be provided: “We give them encouragement, put them in school, wash, dress and feed them, play with them.” Two healers who were attached to a hospital with a mental health unit said they would refer to them. They expressed particular difficulty in treating children who are born with mental disorders.
Christian Healing Ministries
Pastors and other workers in Christian Healing Ministries told us that children and adolescents are usually brought in for a variety of reasons, e.g. witchcraft, spiritual problems, demonic attacks, seeing devils, (witch) dreams or adolescents having spiritual husbands or wives which appear to them in dreams. The observed behaviour of these children was described in various ways, e.g.: They begin to behave differently, they are disobedient, spoil property, are stubborn. They talk in their sleep. They wet their beds. Some start stealing. They have wet dreams. They experience continuous sickness. There can be entire lifestyle changes. They become wicked. They have no fear. They fall on the ground and begin to foam.
Problems are identified by Christian Healing Ministry workers through counselling and listening, observation of behaviour, fasting, prayer and divine revelation. Help is mostly offered in the form of counselling, prayer and fasting (for which parents and children can be encouraged or are requested to join), “deliverance” (being released from evil forces such as demons) and Bible-teaching. One church offered residential treatment, sometimes for children as young as 9 years old. Another church said to sometimes give financial assistance to parents or children. They also help with family reintegration and advocate for education for adolescents that come to them for help. One pastor told us that when younger children do not improve, he sometimes refers them to the MHC Provider present in the same town.
Local explanations of child mental health
The Krio expression noto ospitul sik is commonly used for both physical and mental ailments that are believed to be beyond treatment with allopathic medication: a sickness which cannot be healed in a hospital, because the cause of the sickness is not physical but spiritual/supernatural. An analysis of all data related to aetiology showed that CAMH problems are often considered to belong to this category. Participants frequently spoke of curses, witchcraft, demon-possession, sacrifices and the breaking of taboos. Children can be afflicted by the supernatural in various ways. They can be considered victims or perpetrators or both. People can use witchcraft against them, for instance in the context of jealousy in polygamous homes. Sometimes older people transfer their witchcraft powers to children, for example grandmothers to their grandchildren. Some children are believed to enrol themselves in occultism, but is also possible that powers from the supernatural world take the initiative. A common way for this to happen is when devils appear to a child at the water side and/or attach themselves to the child through gifts (monetary or otherwise), luring them into sorcery and witchcraft. Affliction by the supernatural can also be caused by the breaking of taboos. Both a Traditional Healer and a Christian Healing Ministry worker spoke of the risk a pregnant woman runs when washing herself outside at night: the devils who are roaming around at this time will enter the woman’s navel and disturb the child. In several contexts participants mentioned the possibility that parents had made sacrifices to demons in order to obtain power or wealth. Participants in the Group Interview explained that the Krio expression for this is “Noto fo natin”: i.e., there is always a reason why something happens.
While Traditional Healers and Christian Healing Ministry workers almost exclusively identified causes in the spiritual realm, other groups of participants also gave alternative reasons for children to develop mental health problems. Primary health care providers frequently mentioned physical causes for mental health problems: brain-damage due to accidents or physical illness (malaria, meningitis), birth injuries, the effects of some prescription drugs or the use of native herbs during pregnancy, etc. On an inter-human level, participants cited stress related to the family (change of caregivers, separation or divorce of the parents, abuse, child rearing issues) and stress related to the school or community. Participants also mentioned socio-economic factors (poverty) as a possible cause for mental health problems. Two MHC Providers and participants in the Group Interview mentioned the ongoing consequences of war as a potential cause.
One situation illustrative for the co-existence of different local explanations was observed when visiting a Christian healing Ministry. A small child, physically disabled and seemingly intellectually delayed or disabled, was lying on a mattress on the floor. The first author enquired after her condition and received the following answer:
“She was born this way. The doctors say she is mentally retarded. But counselling by the pastor revealed that the father of the child was involved in demonic business, with an agent of darkness. The serpentine spirit then came and made the mother pregnant. This child is now the manifestation. Through prayer she is now improving.”
Help-seeking behaviour and the role of alternative care
The limited child and adolescent caseloads we found at MHC Providers were mentioned before. While it was difficult to obtain hard data on the caseloads of traditional healers and Christian healing ministries, both groups were able to share in-depth information about the cases they dealt with (which include physical disorders) and said children were brought to them frequently (one Christian healing ministry mentioned 15–20 children per week). Parents reported to seek help from different sources. While allopathic medication was used for physical ailments, the child was taken to traditional and religious healers for treatment of mental health problems. The financial implications of this help-seeking behaviour appeared to put a significant strain on families. This is illustrated by the case of Hawanatu (not her real name), a girl who developed autistic features after a series of seizures at a young age:
Hawanatu’s parents took her to the church, the mosque and an herbalist. At the church, the parents had to pay 150,000 leones (approx. $35). People at the church would pray for Hawanatu for many hours. They also blessed water and gave it to Hawanatu to drink. At the mosque they prayed for Hawanatu and the parents didn’t have to pay. The Muslim herbalist said it was a devil and gave them medicines (leaves) and “lasmami” (verses from the Quran written on a slate and washed off with water, which then is believed to have healing powers). Hawanatu’s mother explained that herbalists can be very expensive. They can charge 1,000,000 leones (approx. $225) which after bargaining they may bring down to 700,000 or 800,000 leones (approx. $160–180). Hawanatu’s parents spent a significant sum of money on their daughter as they visited several places.
During the feedback meeting several participants expressed doubts about the accuracy of our findings on the role of traditional healers in child mental health care. It was felt that the research presented a picture of traditional healers which was too positive. Participants expressed concern over the abuse they believed to be going on: high financial or material demands, chaining, beating, and keeping children under inhumane conditions. It was said that some children do not survive the “treatment”.
Stigma
We found examples of the different dimensions of stigma as suggested by Mukolo (stereotypes, discrimination and devaluation), targeting the three groups included in the model: children with mental disorders, families/associates and service providers. The examples we present here are mostly related to children with easily perceptible cognitive limitations.
Stereotypes could be found in the terms used to describe children with mental disorders, e.g. wicked, stubborn, or retarded.
Discrimination often directly affects the children. A teacher told us how children with mental disorders often face difficulties when taking public transport. Families of children with mental disorders reported being forced to move frequently. On a service level, a teacher told us how she was sometimes discriminated for working at a “Special Needs School”:
“At times, when they look at me, they can look at me as if I am crazy. Because this is a ‘mentally retarded school’.”
Discrimination of children with mental disorders frequently results in child abuse or exploitation. Participants told us stories about children being chained or beaten. Girls with mental retardation are believed to be at increased risk of sexual violence. Their cases are not followed-up as the children cannot give evidence. Other children are subjected to child labour; they are given “filthy jobs to do” (group interview).
Looking at the
context of stigma, we found that discrimination is often brought on by the general public, but also takes place on institutional level:
“Slow learners are beaten by the teachers and parents withdraw them from school.” (group interview).
Devaluation was often targeted at the child, e.g.
“People feel they [children with mental disorders] are outcasts. They feel they are not human beings.” (Teacher Special Needs School)
“Children with mental health problems are considered a curse.” (Group Interview)
“People feel they [children with mental disorders] are not functioning properly. They cannot contribute towards the development of the community.” (Teacher Special Needs School)
We did not find examples of self-stigmatisation, but a mother expressed how she wrestled with the public opinion about her child:
“They say, we gave birth to a debul (demon). But it is not true. She got up and she walked. If she were a debul, she’d sit down, she won’t walk. But this one, I don’t think this is a debul.”
Stigma as an obstacle for parents to bring their child for treatment was mentioned by one informant, an MHC Provider in Freetown.