Manasi Kumar, PhD, CPsychol Manasi Kumar, PhD, CPsychol. Senior Lecturer, Department of Psychiatry University of Nairobi First Annual Conference on Child Behavioral Health in Sub-Saharan Africa 12-13th July 2016 Kampala, Uganda

Remit of the panel discussion What are the pressing child mental health challenges within specific countries? What is the current child and adolescent mental health services infrastructure in each of the three countries? What are the competing issues children, adolescents and families face (e.g. poverty, HIV, conflict, interpersonal violence, trauma, lack of economic opportunities) that impact child behavioral health? How can stigma be effectively addressed within specific country contexts? What role can professionals, community, cultural and religious leaders play in creating effective approaches to child behavioral health?

Key Facts on Child Health land area of 580,000 km2 population of over 43 million with a life expectancy of 59 years under 5 - 5.9 million children died in 2015 in SSA. Kenya is ranked no 39 globally in under 5 deaths. About 45% of all child deaths are linked to malnutrition. Children in sub-Saharan Africa are greater than 14 times more likely to die before the age of 5 than children in developed regions Infectious diseases with neuropsychiatric sequelae such as malaria and HIV/AIDS are more prevalent than elsewhere in the world (Global Burden of Disease Study, 2015) including greater burden of neuropsychiatric deficits associated with epilepsy Source: Commonwealth secretariat of Kenya (Phillips Owen et al (2016)Child and adolescent mental health in sub-Saharan Africa: a perspective from clinicians and researchers BrJPsych International)

Rise in NMS disorders in late childhood and adolescence Disability-adjusted life years (DALYs) for each neurological, mental health and substance-use (NMS) disorder in 2010 by age. Davidson et al (2015). Nature 527, S161–S166 (19 November 2015) doi:10.1038/nature16030

Key Facts in Child Behavioral Health In LMICs, estimated one in 7 children and adolescents have significant difficulties, with 1 in 10 (9.5%) having a specific psychiatric disorder (LMIC wide study) Arch Pediatr Adolesc Med. 2012;166(3):276-281. doi:10.1001/archpediatrics.2011.592. While diagnostic psychiatric interviews are necessary for meaningful research, few or no diagnostic interviews have been validated in an African context, particularly among the expanding poorer sections of society Multiple languages within a single region can sometimes act as a barrier for behavioral health assessment

Risk and Protective Factors for Poor Behavioral Health Clear socio-demographic correlates of psychopathology that place children in areas of greatest deprivation at greatest risk (Cortina et al 2012 –A systematic review in SSA ) Adverse social circumstances such as war trauma, child abuse and neglect, being orphaned, food insecurity and poverty are significant risk factors Protective factors such as parental sensitivity and positive parenting, support from extended family, siblings, and teachers etc haven’t been adequately studied

Parenting & Child Behavioral Health Research in LMICs focusing on Kenya Child Behavioral Health Research Focuses in LMICs Social Determinants of Parenting Pregnancy, poverty and parenting Maternal-Child Mental health Ethnic conflict and child development

Poverty and Related Social Determinants for Poor Parenting: Kenyan evidence Adolescents from lower SES have higher attachment and emotional & conduct difficulties than those from middle to high SES. It was also seen that their attachment style is more of avoidance than anxious style (Wambua et al 2015) N=137 VASQ and SDQ. Absence of sensitivity of parenting (main aspects of sensitivity were associated with disciplinary methods and child’s access to education), child’ birth order and greater responsibility accorded to the firstborn girl child, parental emotional unavailability, and severity of inter-parental conflicts and child’s level of exposure to it predicted insecurity of attachment to parents (Polkonikova-Wamoto et al. 2016) 8-15 years, N=20

Maternal Depression & Child Well Being Depressed mothers were 7 times more likely to not engage in exclusive breastfeeding and were 4 times more likely to have babies who were underweight (Madeghe et al 2016) infant age 0-6months Fear of contagion (AOR= 17.91 [1.01 - 39.06] p<0.05) and Negative Self perceived stigma (AOR= 5.59,95% CI[2.59-12.65],P<0.05) highest in depressed women attending PMTCT (Obadia et al 2016) – one can imagine the impact on parenting Low infant birth weight was 2.24 times more among the women with depression (Mochache et al. 2016,) Intimate Partner Abuse the most frequently found reason behind depression and child neglect aside from abandonment by partner/loss of income by woman (MCMH group)

Maternal Depression…. Depressed mothers were likely to have Stunted children than non Depressed mothers (N=148). SC scored poorly on KABC fluid intelligence tests than non stunted children. (M of NSC was 69.17 compared to 50.71 for SC (Mbelenga, et al. 2015) In a study by Githara et al (2016) on depression and stigma in caregivers of children with intellectual impairments, it was found that those divorced or separated caregivers faced increased unfair treatment compared to single caregivers (OR: 7.84 [2.79 – 118.38], p – value = <0.0001) and there is reduced ability to overcome stigma as levels of depression increase.

Ethnic conflict & Child Behavioral Health Children who experienced 2007/2008 post-election violence had a high level of PTSD 75.45%. Findings showed that there are tremendous differences in traumatic experiences between children in the violence ridden areas and those in areas which did not witness violence and that there is a significant difference in the level of PTSD between pupils who experienced communal violence and those who did not (Muola, 2013) I have worked on attachment trauma post witnessing of violence in children and adolescents. Families and interpersonal relationships are affected in the way violence touches lives of people

Child Behavioral Health Research Gaps In Kenya Lack of research using community samples or school age children Lack of child behavioral health research Prevalence research Psychopathology/risk mechanism testing research Parenting and child development research Lack of evidence-based maternal and child mental health or implementation research What are the competing issues children, adolescents and families face (e.g. poverty, HIV, conflict, interpersonal violence, trauma, lack of economic opportunities) that impact child behavioral health?

Ongoing Research In Attempts to Address the Child Behavioral Health Research Gaps (Kumar, et al., 2015-)

Kenya Families from Two Communities Research Evidence (Kumar et al, 2015) N=437 (91% mother, 3% father, 6% other) Child Characteristics 51% girls & 49% boys Age range 1-13; 17% (n=74) under 3 years old; 63% (n=276) 3-8 years old; and 20% (n=87) above 9 years old Family Characteristics/Risks 62% food insecure 27% unemployed 34% parents had primary or less education 33% parents had moderate to severe depression On average, families have 2.71 (SD=1.28) children 68% married (32% single)

Child Behavioral Health Problem Behavior Prevalence CBCL Validation (Kiswahili version) Using the developers’ norm sample, we found 19% of Kenya children were at-risk (above 84 percentile) for INT problem (T >=60) and 11% were at-risk for EXT problem (measured by CBCL). For clinical-level problem (above 98 percentile, or T score >=70): 6% Kenyan children had INT problems and 3% had EXT problems No child age group(under 3, 3-8, and 9-13 years old groups) or gender group differences on problem behavior prevalence

Psychopathology for Poor Child Behavioral Health Stress Contexts & Parenting In attempt to validate parenting measures and study parenting and child development research questions NOT TO FOCUS ON PARENTING MEASURES Parental Stress and contexts include depression, social support, food insecurity, parental health Consistent with the literature, We found stressful living contexts have negative influence on parenting We found evidence that parental depression, health, food insecurity and low social support were associated with poor parenting (discourage their children to express negative emotion, provide less stimulation for their children, have more conflicted parent-child relationship)

Parenting & Child Behavioral Health Parent Stimulation 1.      How many times in the past week did you play with (CHILD) 2.      How many times in the past week did you sing to or play music to (CHILD) 3.      How often do you talk to (CHILD) while you are working around the house? Would you say …