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.

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.

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

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.

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.

Psychosocial dynamics of psychoactive substance misuse among Nigerian Adolescents

Background: Psychoactive substance misuse has for many years been an issue of increasing health and social importance in Nigeria. This is especially so for the critical adolescent period marked by several changes including the psychological phenomenon of experimentation. Studies carried out in the last two decades in Nigeria have identified adolescents as a major group involved in the use of psychoactive substances. However, most studies employed quantitative methods to gather information on drug misuse. In developing programmes for prevention and control of drug misuse it is important to complement quantitative information with qualitative data. This article reviews the available data on drug use in Nigerian adolescents and utilises a qualitative method to explore the psychosocial dynamics of drug use among adolescents. Methods: Review of current literature on drug use among adolescents in Nigeria and in-depth interviews of two adolescents with poly-drug misuse to identify psychosocial dynamics surrounding their use of psychoactive substances. Results: Surveys suggest that in both in-and out-of-school adolescents, the socially acceptable drugs like alcohol and cigarettes are commonly used. The patients interviewed illustrate the important 'gateway' theory of drug progression. Psychological dynamics identified include peer pressure, experimentation and conduct problems while social factors include poverty, family problems, and social acceptability of local alcoholic drinks like palm-wine. Conclusion: These identified factors must be utilised in developing drug prevention programmes. The public health implications of the social acceptability of palm wine, especially its consumption by children, needs to be further explored

Influence of gender on undergraduate performance in psychiatry at Ibadan, Nigeria.

OBJECTIVE: This study examined the influence of gender on undergraduate performance in psychiatry among final year medical students at the University College Hospital, Ibadan, Nigeria. METHODS: Results in all parts of the examination in psychiatry for the 2001 graduating class were obtained. In addition, performance scores were obtained for entrance examinations to medical school, preclinical subjects (anatomy, physiology and biochemistry) and clinical subjects (paediatrics, obstetrics and gynaecology, internal medicine and surgery). The mean marks according to gender, with 95% intervals, were calculated and tested for significance. RESULTS: A total of 234 students (160 men and 74 women) took the examinations in psychiatry. Women performed better than men in both the multiple choice questions (MCQ) examination (P = 0.0044) and the clinical assessment (P= 0.0000063). The women were significantly younger than the men (P = 0-0000007) and performance in both parts of the examination decreased with increasing age. There were no differences between the genders in entrance examination scores or preclinical scores but there were significant differences between the genders in performance in clinical subjects such as paediatrics, obstetrics and gynaecology and internal medicine. CONCLUSION: Women performed better than men in all parts of the psychiatry examination, with the difference being more marked in the clinical aspect. A superior performance on the part of women was noted in all clinical subjects. However, where an examination did not involve verbal interaction, there was no difference in performance between the genders. A direct correlation between increasing age and decreasing performance in examinations was also seen.

Brief psychotic disorder in a middle aged Nigerian following the terrorist attacks in America-case report.

This case report illustrates the sudden onset, brief course and remission of a psychotic illness in a middle-aged Nigerian starting soon after she heard about the terrorist attacks in America. Vulnerability factors including personality traits and other concurrent life events were identified in the patients. Common mental disorder associated with terrorist attacks, disasters and armed robbery, and the need for health workers to be sensitised to these disorders are discussed in light of the ongoing violence in parts of Nigeria.

Children with mental disorders in primary care: functional status and risk factors.

Using data derived from a large epidemiological survey of children attending a pediatric primary care clinic, this article reports the relationship between the presence of mental disorders and functional status and the risk factors for depressive, anxiety-related and conduct disorders in these children. The results suggest that children with mental disorders in primary care are more functionally impaired than those without such disorders, with depressive and conduct disorders more often associated with such impairment. Analysis using logistic regression analysis to determine risk factors showed that broadly different familial and antecedent features predicted the presence of these groups of disorders. The findings confirmed the salience of factors relating to family and socioeconomic status and of maternal psychological health in a culture characterized by the extended family structure and widespread economic deprivation.

Psychiatric disorders in a paediatric primary care clinic.

BACKGROUND: The proportion of children with psychiatric disorders treated in primary care is not known in most developing countries. METHOD: In a two-stage epidemiological study, 990 children aged between 7 and 14 years were screened with the parents' version of the Rutter scale. Of these, a stratified sample of 227 was interviewed jointly with their mothers, using the children's version of the Schedule for Affective Disorders and Schizophrenia (K-SADS). RESULTS: We obtained a weighted prevalence of 19.6 +/- 2.5% for the presence of one or more DSM-III-R disorders. Depressive disorders were present in 6.0%, anxiety-related disorders in 4.7%, and conduct disorders in 6.1%. CONCLUSION: Psychiatric disorders in children are common in primary care. Doctors working at this level of care need the skills to detect and treat them.