Reprioritising global mental health: psychoses in sub-Saharan Africa.

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Prevalence and Correlates of ADHD Among Adolescent Students in Nigeria.

OBJECTIVE: To determine the prevalence and psychosocial correlates of ADHD among adolescents in Jos, Nigeria. METHOD: A cross-sectional descriptive two-stage study of 487 randomly selected participants using Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL), Raven's Standard Progressive Matrix (SPM) and the Children's Global Assessment Score (CGAS). RESULTS: The prevalence of ADHD was 8.8%. The subtypes found were inattentive (3.08%), hyperactive-impulsive (2.05%), and combined (3.08%); male:female ratio of 1.4:1. ADHD was significantly associated with use of substance by father (odds ratio [OR] = 0.35; 95% confidence interval [CI] = [0.154, 0.781]), use of substance by mother (OR = 0.2; 95% CI = [0.055, 0.711]), and lower education of mother (OR = 0.3 95% CI = [0.116, 0.693]). Poor quality of handwriting (χ2 = 8.120; p = .010) and impaired global functioning ( t test = 10.756; p < .001) were significantly associated with ADHD in the adolescents. CONCLUSION: Given the burden of ADHD, efforts should be made to establish a system for the early identification and management.

Pattern of impairments and late diagnosis of autism spectrum disorder among a sub-Saharan African clinical population of children in Nigeria.

BACKGROUND: Autism spectrum disorder (ASD) is a complex group of neurodevelopmental disorders. Studies conducted among Africans living outside the continent indicate that African children are more likely than Caucasian children to have a late diagnosis of ASD. There is a dearth of information on this topic among children with ASD living in Africa. METHODS: To determine the pattern of impairments and age at diagnosis in ASD, sixty Nigerian children with a diagnosis of ASD were recruited from a neurodevelopmental clinic. DSM-V criteria were used to make a diagnosis of ASD, while a symptom checklist for ASD was used to determine the pattern of impairments in ASD. RESULTS: Ages of the children ranged from 2 to 17 years with a mean age of 9.45 ± 4.33 years with the majority of them (75%) being 12 years or younger. All the children (100%) with ASD exhibited poor eye contact, difficulty in mixing with other children and inability to consistently respond to his/her name. More than a half of them (55%) lack verbal communication. Impairments that were uncommon are in the areas of object attachment (20.0%), odd postures (26.7%) and inappropriate facial expression (30.0%). Mean age at the observation of ASD features was 17.0 ± 6.7 months. Mean age at diagnosis of ASD was 9.00 ± 4.30 years. The mean time lag from a parental concern of ASD features to seeking specialist care was 85 months and to diagnosis was 91 months. CONCLUSIONS: Core symptoms/impairments of ASD are present in Nigerian children but a late diagnosis is common.

ADHD Among Rural Southeastern Nigerian Primary School Children: Prevalence and Psychosocial Factors.

OBJECTIVE: To determine the prevalence of ADHD among primary school pupils in a rural community in Southeastern Nigeria and to determine the psychosocial factors associated with the condition. METHOD: One hundred eighty-one randomly selected participants had their teachers complete the school version of ADHD Rating Scale-IV. Their parents also completed a sociodemographic questionnaire, the clinical interview form for the child and adolescent ADHD patients, and home version of the ADHD Rating Scale-IV. RESULTS: Twelve (6.6%) of the children met the criteria for diagnosis. A history of prolonged labor (odds ratio [OR] = 14.1; 95% confidence interval [CI] = [2.13, 93.1]), and parents' negative assessment of their marriages (OR = 0.1; CI = [0.017, 0.567]) were the most predominant factors which independently associated with the ADHD in the children. CONCLUSION: There is, therefore, a need for the care of rural dwelling African children, who otherwise would have difficulties accessing health care that is concentrated in the cities.

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) among Rural Primary School Children in Southeastern Nigeria: Comparison of School and Home Settings

Background: Diagnosis of ADHD depends on manifestation of symptoms in at least two different settings. This therefore emphasizes the importance of multiple informants; parents and teachers. However perception could differ because of differences and inconsistencies across different settings. This is particularly important in rural settings in Africa where the educational attainment and outlook of teachers are very different from those of the parents. The study is aimed at comparing the presentations of children with ADHD in the rural area; across two different settings: home and school. Methods: The teachers of 181 rural primary school children in Ogberuru in Imo state; south eastern; Nigeria completed the school version of ADHD rating scale-IV; and their parents completed a Socio demographic questionnaire and the home versions of the ADHD rating scale IV. Results: Of the 18 symptoms of the condition; there were significant differences in the rate of identification in eight symptoms. These symptoms include 'being easily distracted' (p=0.0427); 'difficulty following through on instruction' (p=0.0026); 'fails to give close attention to details (p=0.0001); 'avoids tasks necessary for tasks' (p=0.0013); 'difficulty playing quietly (p=0.0059 ) ; 'talks excessively' (p=0.0023); 'intrudes on others' (p=0.0004); and 'seems not to listen when spoken to directly' (p=0.0002). They were all consistently more manifest in school settings than in their homes. Conclusion: Teachers identified ADHD symptoms more commonly than parents. They could therefore play critical roles in programs aimed at improving early identification and management of children with ADHD especially in rural Africa where healthcare facilities are scarce

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) among Rural Primary School Children in Southeastern Nigeria: Comparison of School and Home Settings

Background: Diagnosis of ADHD depends on manifestation of symptoms in at least two different settings. This therefore emphasizes the importance of multiple informants; parents and teachers. However perception could differ because of differences and inconsistencies across different settings. This is particularly important in rural settings in Africa where the educational attainment and outlook of teachers are very different from those of the parents. The study is aimed at comparing the presentations of children with ADHD in the rural area; across two different settings: home and school.Methods: The teachers of 181 rural primary school children in Ogberuru in Imo state; south eastern; Nigeria completed the school version of ADHD rating scale-IV; and their parents completed a Socio demographic questionnaire and the home versions of the ADHD rating scale IV. Results: Of the 18 symptoms of the condition; there were significant differences in the rate of identification in eight symptoms. These symptoms include 'being easily distracted' (p=0.0427); 'difficulty following through on instruction' (p=0.0026); 'fails to give close attention to details (p=0.0001); 'avoids tasks necessary for tasks' (p=0.0013); 'difficulty playing quietly (p=0.0059 ) ; 'talks excessively' (p=0.0023); 'intrudes on others' (p=0.0004); and 'seems not to listen when spoken to directly' (p=0.0002). They were all consistently more manifest in school settings than in their homes. Conclusion: Teachers identified ADHD symptoms more commonly than parents. They could therefore play critical roles in programs aimed at improving early identification and management of children with ADHD especially in rural Africa where healthcare facilities are scarce

Autistic disorder in Nigeria: profile and challenges to management.

Autism represents one of the most common developmental disorders affecting children, but there are few reports on autism in African children. Our study describes the profile of autistic disorder in a cohort of Nigerian children and appraises short-term outcomes. Children seen at the pediatric neurology and the child psychiatry clinic of the University College Hospital, Nigeria were screened for autistic disorder using the American Psychiatric Association's Diagnostic and Statistical Manual IV. Forty-five males and 9 females were identified with autism, and the disease accounted for 2.3% of 2320 new cases seen during the period. The mean age at which parents observed deviations in behavior was 22.5 (SD=6.6) months, while the mean age at diagnosis was 44.7 (SD=21.2) months. Twelve (22.6%) children had a positive family history of autism, and forty (75.5%) had associated neurological comorbidities. Diagnosis of autism is often delayed in Nigeria, and affected children have a high frequency of neurological comorbidities.

Neurological and intellectual disabilities among adolescents within a custodial institution in South-West Nigeria.

A total of 67 adolescents from a juvenile remand home were matched with 67 other adolescents by age and gender, with a view to determine the prevalence and spectrum of neurological and intellectual disabilities. Intelligence quotient (IQ) was estimated using an adapted version of the Slosson's Intelligence Test and a full neurological evaluation was carried out. The mean IQ score for the remand home participants was significantly lower than the controls (77 ± 11 vs. 99 ± 14; t = 1.6, P = 0.001). Almost half (46.7%) of the participants in the remand home had intellectual disability of varying degrees, including borderline intellectual functioning, compared with only two (3.3%) of the comparison group (P < 0.001). Epilepsy and neurological deficits were significantly more prevalent among the remand home group, particularly those admitted as victims of neglect, compared with the comparison group (P ≤ 0.02). These findings and recent literature were used to speculate the possible underlying factors. Policy implications for child social welfare in Nigeria were suggested.

Mental health problems in Nigerian children with epilepsy: associations and risk factors.

Epilepsy is the most common neurological disorder affecting children, and the greatest burden of childhood epilepsy is found in the developing countries of the world. Behavioral problems are reported to occur more frequently in children with epilepsy, but there are limited studies on the pattern of behavioral problems in children living with epilepsy in sub-Saharan Africa. Eighty-four consecutive cases of epilepsy aged ≥5 years seen at the pediatric neurology clinic of the University College Hospital, Ibadan, Nigeria over a period of 9 months were screened for behavioral problems using the Rutter A2 scale. Behavioral problems were found in 39 (46.6%) of 84 subjects and occurred more frequently in males. Presence of associated learning difficulties (OR 5.13, 95% CI 1.61-16.36) and being diagnosed with epilepsy within 6 months of the onset of the first epileptic seizure (OR 4.54, 95% CI 0.073-0.69) independently predicted psychopathology in the cases studied. Emotional and behavioral problems are common in Nigerian children with epilepsy. There is a need for effective mental health services for children with epilepsy in order to optimize outcomes.

Children within the juvenile justice system in Nigeria: psychopathology and psychosocial needs.

BACKGROUND: Many children in Nigeria face a life of poverty, family instability, inadequate educational opportunities and poor physical and mental health which hinder their ability to develop into healthy adults, live an improved quality of life or fulfil their life aspirations. These factors have also been associated with juvenile delinquency and need for institutional care. OBJECTIVES: As a step toward providing comprehensive services for incarcerated children in Nigeria, this study aimed to identify the psychosocial needs as well as types of psychopathology among a group of incarcerated children at the Ibadan remand home. METHODS: A cross-sectional survey of children and adolescents at the Ibadan remand home was carried out using a semi-structured questionnaire. RESULTS: A total of 59 children were assessed over a one year period. Majority (90%) were in need of care and protection. All (100%) had significant psychosocial needs presenting as difficulty with their primary support, economic, social environment, or educational systems. Majority (97%) also demonstrated significant psychopathology and anxiety, suicidal and depressive symptoms were the most commonly elicited. CONCLUSION: Incarcerated children in this study showed significant mental health needs which need to be addressed as a matter of urgency. This should be carried out through the collaborative efforts of mental health professionals with various stakeholders in child care.

Children within the Juvenile Justice System in Nigeria: Psychopathology and Psychosocial Needs

Background: Many children in Nigeria face a life of poverty; family instability; inadequate educational opportunities and poor physical and mental health which hinder their ability to develop into healthy adults; live an improved quality of life or fulfil their life aspirations. These factors have also been associated with juvenile delinquency and need for institutional care. Objectives: As a step toward providing comprehensive services for incarcerated children in Nigeria; this study aimed to identify the psychosocial needs as well as types of psychopathology among a group of incarcerated children at the Ibadan remand home. Methods: A cross-sectional survey of children and adolescents at the Ibadan remand home was carried out using a semi-structured questionnaire. Results: A total of 59 children were assessed over a one year period. Majority (90) were in need of care and protection. All (100) had significant psychosocial needs presenting as difficulty with their primary support; economic; social environment; or educational systems. Majority (97) also demonstrated significant psychopathology and anxiety; suicidal and depressive symptoms were the most commonly elicited. Conclusions: Incarcerated children in this study showed significant mental health needs which need to be addressed as a matter of urgency. This should be carried out through the collaborative efforts of mental health professionals with various stakeholders in child care

Children within the Juvenile Justice System in Nigeria: Psychopathology and Psychosocial Needs

Background: Many children in Nigeria face a life of poverty; family instability; inadequate educational opportunities and poor physical and mental health which hinder their ability to develop into healthy adults; live an improved quality of life or fulfil their life aspirations. These factors have also been associated with juvenile delinquency and need for institutional care. Objectives: As a step toward providing comprehensive services for incarcerated children in Nigeria; this study aimed to identify the psychosocial needs as well as types of psychopathology among a group of incarcerated children at the Ibadan remand home. Methods: A cross-sectional survey of children and adolescents at the Ibadan remand home was carried out using a semi-structured questionnaire. Results: A total of 59 children were assessed over a one year period. Majority (90) were in need of care and protection. All (100) had significant psychosocial needs presenting as difficulty with their primary support; economic; social environment; or educational systems. Majority (97) also demonstrated significant psychopathology and anxiety; suicidal and depressive symptoms were the most commonly elicited. Conclusions: Incarcerated children in this study showed significant mental health needs which need to be addressed as a matter of urgency. This should be carried out through the collaborative efforts of mental health professionals with various stakeholders in child care

Teachers' Perspectives of Mental Health Needs in Nigerian Schools

Objective:This study assessed teachers' perspectives on children's mental health needs and the development of school-based mental health programmes in South-West Nigeria. Method: Focus group discussions were held with teachers from randomly selected urban and rural primary schools in Ibadan; Nigeria. Data were analysed using interpretative phenomenological analysis. Results: Teachers identified significant mental health problems in school-age children and described a variety of bio-psychosocial contributing factors. These ranged from problems with primary support systems to poverty; spiritual factors; medical illnesses and genetic vulnerability. The school environment was recognised as an ideal place for dealing with child mental health issues despite deficiencies in teachers' knowledge; skills and resources. A school mental health programme that would provide training for teachers and awareness campaigns as well as human; material and financial resources was proposed. Conclusions: The findings from this study provide a background for understanding the current state of interventions to address child mental health problems in a resource poor country in sub- Saharan Africa and specific areas where future program development is most likely to have an impact

A case of human bite by an 11-year old HIV positive girl in a paediatrics ward.

Biting is a possible mode of transmission of HIV infection, though the risk of such transmission is believed to be low. Children infected with HIV are at risk of psychological complications as a result of direct or indirect effects associated with the disease. We report the case of an 11 year old HIV positive girl with clinical stage IV disease, who was involved in multiple disputes while on admission on the ward. During one of the disputes she inflicted a deep bite injury on a 10-year old boy, HIV post-exposure prophylaxis (PEP) was commenced 6 hours after the bite and he has remained HIV negative 12 months later. What is peculiar about this case is that the incident occurred in a hospital setting and biting is not usually expected among children of this age. In the era of HIV/AIDS, it is recommended that persons involved in childcare be aware of this potential risk during interactions among children. It is also essential for health care personnel to have sufficient knowledge about PEP in order to reduce the risk of HIV transmission in similar settings. In addition, a multidisciplinary approach to the management of children living with HIV is important in order to identify and address psychosocial factors that may influence symptoms and medical treatment outcome. The risk of transmission of HIV through human bites and the psychosocial impact of the disease on children are also discussed.

Suicide attempt by hanging in preadolescent children: a case series.

BACKGROUND: Suicide is now among the five top causes of death in youth worldwide. However, during the preadolescent period, suicidal behaviour is rare and difficult to define because the cognitive level of young children limits their ability to plan and understand the consequences or the finality of suicide. There is virtually no information about preadolescent suicidal behaviour in Nigeria. OBJECTIVE: To illustrate the presentation and psychosocial issues associated with preadolescent suicidal attempt using the 'hanging' method in Nigeria. METHODS: Three case scenarios of suicide attempt by hanging in preadolescents seen at the University College Hospital, Ibadan between 2005 and 2006 were interviewed in detail along with mental state and physical examination. Family and individual therapies were embarked upon. RESULTS: Types of psychopathology found in the preadolescents include depressive symptoms, conduct and oppositional defiant disorder and impulse control problems. Stressful life events such as family disruption, physical abuse, and bullying at school were factors associated with suicidal behaviour. The influence of the media in providing information about 'hanging' as a method of suicide was evident. Therapy yield varying results. CONCLUSION: High risk parameters for suicide in children should be known to all health professionals. The importance of intervention strategies particularly media education, monitoring systems and further research on suicidal behaviour in this environment is apparent.

Psychosocial issues in a child and adolescent psychiatric clinic population in Nigeria.

BACKGROUND: Psychosocial issues and interventions play a very important role in the aetiology, course and prognosis of several child psychiatric disorders. Psychosocial problems in a child and adolescent psychiatric clinic population in Nigeria were documented as a preliminary step towards the planning and development of this new facility. METHODS: A standardised assessment procedure was integrated into the routine at the clinic when services commenced. Psychosocial stressors and life events were measured using the interview method so that in-depth information could be obtained. RESULTS: Over the 3-year period of study, 79 (62.2%) of the 127 new referrals to the clinic had significant psychosocial stressors in the year preceding presentation. Problems with primary support, such as separation from parents to live with relatives, disruption of the family, abandonment by mother, psychiatric illness in a parent and sexual/physical abuse, occurred in 50 (39.4%) of the subjects. Problems with social environment occurred in 11 (8.7 %), 39 (30.7 %) had educational problems, 5 (3.9%) had economic problems and 15 (11.8%) of the children had "other" psychosocial stressors. Significantly more children and adolescents with disruptive behaviour disorders and disorders like enuresis, separation anxiety and suicidal behaviour had psychosocial stressors when compared to children with psychotic conditions, autistic disorder and epilepsy (chi(2) = 9.6; p = 0.048). CONCLUSIONS: The importance of the psychosocial diagnostic dimension in routine practice is illustrated in this study. Some psychosocial factors identified are cultural practices. The effects of these practices on child mental health require further study.

Computed tomography and childhood seizure disorder in Ibadan.

BACKGROUND: Computed Tomography (CT) is an important tool for neuroimaging, it offers an opportunity to investigate structural lesions as a cause of seizures with little morbidity. This study is designed to evaluate it's applicability in children with epileptic seizures. METHOD: It is a descriptive study of the CT scans of the 103 consecutive children who were referred to the CT suite of the University College Hospital on account of seizure disorders over a 5 year period (1997--2001). RESULTS: Only 103 (4.6%) of the subjects who had cranial scans done in five years were children with seizures disorders. The CT scans were abnormal in 53 (51.5 %). Hydrocephalus was the most common finding in 14 (13.6%). Cerebral atrophy and infarct were reported in 10.6% and 8.7% respectively. The outlined cranial fractures found in 6.8% were all depressed. A high incidence (74.4%) of abnormal scans was reported in the children with partial seizures. Thirty-three (62.3%) of the abnormal scans were amenable to surgery. The presence of neurologic deficit increased the yield of abnormal CT features. CONCLUSION: CT scans are of extreme value in the screening and definitive evaluation of seizures in children. It is advocated for excluding treatable conditions and monitoring progression of the disorder.

Ovarian cancer in Ibadan: characteristics and management.

Ovarian cancer has the highest case fatality rate among gynaecological cancers worldwide because of lack of effective screening methods and non-specific early warning symptoms with late presentation. A reinvigorated study is necessary in the developing countries because of a projected increase in its incidence. The decreasing fertility rate and increasing use of ovulation induction drugs are some of the reasons. The Ovarian Cancer Service of the Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria commenced the first longitudinal study of this malignancy from 1 December 1998 in order to establish a regional management and research centre. It is a questionnaire survey detailing the demography, clinical and staging laparotomy findings and histology of all confirmed cases. Twenty-one staging laparotomy and histologically confirmed ovarian cancer cases were managed from 1 December 1998 to 31 July 2002, about 1.5% of the 1387 gynaecological admissions. It is the third most common of the gynaecological cancers, representing 9.8% of the 214 cases. More than 60% of the patients were 50 years or younger. Only 19% were nulliparous, with 47.6% having had five or more deliveries. Only two patients (9.5%) had used the oral contraceptive pill, for a maximum period of 1 month. Only one patient (4.8%) had a positive family history of cancer. Abdominal swelling was the most common presenting symptom. Eighty-one per cent of the patients presented in Stages III and IV. Epithelial ovarian cancer constituted about 76.2% of the cases. Only 23.8% had adjuvant therapy, consisting of combination chemotherapy using cisplatin-based regimes. The case fatality rate 6 months after surgery was 76%. The ovarian cancer patients in this environment are younger and of higher parity than expected. The risk factors for this disease require further study.