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Psychosocial Wellbeing Across the Childhood to Adolescence
SpectrumOlayinka Olusola Omigbodun
Professor & Head of Psychiatry, University of Ibadan &University College Hospital, Ibadan, Nigeria
Director, Centre for Child & Adolescent Mental Health (CCAMH)
www.ccamh.ui.edu.ng
Psychosocial Wellbeing in Infants, Children & Adolescents
Olayinka Olusola Omigbodun Professor & Head of Psychiatry, University of Ibadan &
University College Hospital, Ibadan, Nigeria Director, Centre for Child & Adolescent Mental Health
(CCAMH)www.ccamh.ui.edu.ng
Outline
1. Identify Psychosocial Factors in Various Contexts of Care
2. Define and Describe ‘Psychosocial’ and Psychosocial Wellbeing
3. Descriptions of Mental Health & its Relationship to Psychosocial Wellbeing
4. Outline a Psychosocial Agenda
Psychosocial Wellbeing
• Teach• Research• Clinical Services• Advocacy
Africa
Nigeria
Nigeria
• Beauty & diversity of Nigeria • 922,768 square kilometres• West Coast of Africa• Africa’s most populous country • 170 million people• 260 different languages• Every fifth black person you meet
in the world would be a Nigerian
Nigeria
Nigeria
‘Nigeria We Hail Thee’
‘Nigeria’s development is something of a paradox. The country is rich but the people are poor. Nigeria is the 6th largest petroleum exporter in the World
SELLING GASOLINE
University Teaching Hospital
University Teaching Hospital
• Infants, children and adolescents attend a tertiary hospital for mental disorders
• Parents/care-givers have taken the difficult decision to access care for an emotional or behavioural concern
• Decision is usually a last resort after other pathways of help have failed to provide solutions
University Teaching Hospital
• Receive referrals from paediatricians, family physicians, social workers, occupational therapists and other child health professionals
University Teaching Hospital
Different situations requiring
mental health assessments:• Attempted suicide• Physical abuse• Sexual assault or abuse• Drug abuse• Acute agitation• Anxiety & depression presenting as headache, abdominal
pain, failure to thrive• Chronic illness of any kind
University Teaching Hospital
• Decision to access mental health care is made by someone else or a system that insists the caregivers must seek help
• Sometimes against the caregivers wish– School excludes child until help is sought
University Teaching Hospital Psychosocial Issues in the
Child & Adolescent Psychiatric Population
Questions to be answered included:What is the association between specific
psychosocial factors and mental disorders? What influence does culture have on the
manifestation of psychosocial factors?
Omigbodun O. O..(2004) Psychosocial issues in a child and adolescent psychiatric clinic population in Nigeria.
Social Psychiatry and Psychiatric Epidemiology Vol 39 No 8, 667-72
Psychosocial Issues in theChild & Adolescent Psychiatric
Population • Study was carried out based on well established
facts that: Psychosocial factors play an important role in the
aetiology of several child & adolescent mental disordersPsychosocial factors have been found to affect the
course and prognosis of disorders Psychosocial interventions have been found to reduce
and prevent disorders Psychosocial interventions promote mental health
Omigbodun, 2004
62.2%
Significant Psychosocial stressors present in the year preceding
presentation to the clinic were identi-fied in 62.2% of the patients
Psychosocial Issues in theChild & Adolescent Psychiatric
Population
0% 10% 20% 30% 40% 50%
Proportion of Patients
Primary Support
SocialEnvironment
Educational
Economic
Others
Str
es
so
rsPsychosocial Stressors in the Patients
Specific Psychosocial Stressors Identified
Problems With Primary Support Group
Separation From Parents 10 (17%)
Disruption of Family 8 (14%)
Abandoned by Mother/Parents 3 (5%)
Serious Psychiatric Illness in a Parent 11 (19%)
Sexual/Physical Abuse/Emotional Neglect 7 (12%)
Problems Related to the Social Environment
Living on the Streets & Other Severe Conditions 7 (12%)
Living Group Home 5 (9%)
Adapted from Omigbodun, 2004
Specific Psychosocial Stressors Identified
Educational Problems
Poor Academic Performance 6 (10%)
Out of School/ Lack of Appropriate School 8 (14%)
Economic Problems
Extreme Poverty 4 (7%)
Other Stressors
Pressure on Parents to Seek Alternate Treatment 3 (5%)
Adapted from Omigbodun, 2004
• Separation from parents to live to more affluent relative or to correct behaviour
• Abandoned children with epilepsy
• Locked up in traditional healer’s homes & religious centres for several years
• Physical abuse to get rid of the demons responsible for conduct problems
• Apply scarification marks to parts of body
Cultural Practices, Beliefs and Social Problems Peculiar to This Environment that Influence
Psychosocial Stressors
Adapted from Omigbodun, 2004
Cultural Practices, Beliefs and Social Problems Peculiar to This Environment that Influence
Psychosocial Stressors
• Children as young as 7 years old working as house-helps
• Living on the street with mentally ill parent for several years
• Prolonged period of fasting for religious purposes
• Tribal marks on face leading to discrimination
• Lack of appropriate school
Adapted from Omigbodun, 2004
University Teaching Hospital Psychosocial Issues in the
Child & Adolescent Psychiatric Population
Questions were answered and interventions developed:
Association between specific psychosocial factors and mental disorders?
Culture has a strong influence on psychosocial factors?
Omigbodun O. O..(2004) Psychosocial issues in a child and adolescent psychiatric clinic population in Nigeria.
Social Psychiatry and Psychiatric Epidemiology Vol 39 No 8, 667-72
Children in Especially Difficult Circumstances (CEDC) - • Three principal & distinct
types (UNICEF, 2005)
Street Children
CEDC – Psychosocial Issues
Working Children
CEDC- Psychosocial Issues
Children within the Juvenile Justice System
CEDC – Psychosocial Routes
Street children
Break links with their families
Abandon formal education
Streets to hawk various wares
Sheer poverty in families
Shift of rural poor to urban areas`
Juvenile Justice System
Street Children – Psychosocial Issues
• 70% Living on street over 2 years• 45% Use Psychoactive Substances• 69% Use Alcohol• 24% Drug Courier• 11% Raped• 50% Sex Work
96.7%
3.3%
Male Female
Aged 8 – 18 years
Street Children – Psychosocial Issues
School Problems of Street Children
46%
27%
47%
0%
10%
20%
30%
40%
50%
Refusal Suspension Truancy
Schooling Status
Olley, 1996
Psychosocial Issues of Street Children
• Could this really be due to poverty only?
• There are gaps in these stories
• What psychosocial factors are acting in concert to create this situation?
Psychosocial Issues of Street Children
• Abandoned early in life to care of Islamic teachers or ‘Mallams’.
• Teachers do not provide for them
• Go on the streets to make a living by begging for alms
• Mallams actually compel them to bring the proceeds of the begging to them
• Constitute the nucleus of miscreants
• Participate in communal conflicts
Northern Nigeria, Almajiri children
Psychosocial Issues of Street Children 3
Northern Nigeria, Almajiri children
Psychosocial Issues of Street Children
Street Children – Psychosocial Issues
• Aged 5-16 years (Mean 11.2 years)• Prevalence of Drug use: 66.2%• Stimulants: 49.7%• Volatile Solvents: 21.5%• Cigarettes: 19.1%• Cannabis: 18.5%• Feelings of loneliness, depressive symptoms & emerging
from a ‘broken home’ are associated with drug use
Abdulmalik J, Omigbodun O, Beida O, Adedokun B (2009). Psychoactive substance use among children in informal religious
schools (Almajiris) in northern Nigeria. Mental Health, Religion & Culture, 12 (6): 527-542
Street Children – Psychosocial Issues
• Reports of School Refusal• School Suspensions & Truancy• School Drop-out• ?Learning Disorders• ?Conduct Disorders
Street Children – Psychosocial Issues
• Is the Almajiri phenomenon a religious or a cultural one?
• How can the children and adolescents involved be salvaged?
• Are the Boko Haram reigning terror in the sub-region, the Almajiris grown up?
Nigerian School Girls:Over One Year in Captivity!
Children Within the Juvenile Justice System
(Remand Home)• Established by the
Nigerian government• Main cities of country
• Purpose of Remand Homes:
• Juveniles who have committed crime
• Children beyond parental control
• Abandoned children (Care & Protection)
Remand Home35 children (23 boys 12 girls)
(Omigbodun & Bella, 2007)
Remand Home
• Abandoned Children – Intellectual Disability, Psychotic illness, Epilepsy
• Children who ran away from home– Reported physical abuse and were not living with their parents
• Only (14%) were attending school
(Omigbodun & Bella, 2007)
Mental Health & Psychosocial Issues Linked to Reasons For Admission
Remand Home 2007 Diagnostic Categories
(Omigbodun & Bella, 2007)
Remand Home 2007
3 ‘witches’ in the home (all girls)
Remand Home 2007
• 7 year old girl• Abandoned by mother• Mother had been traced• Did not want her anymore• Village head had banished her from village
• Mental State – Auditory hallucinations, weepy, withdrawn
First ‘Witch’
Remand Home 2007
• 15 year old abandoned adolescent with mild intellectual disability
• Said to us ‘I am the head of witches’• Mental State• Auditory hallucinations - Voices telling her she is a witch
Second ‘Witch’
Remand Home 2007 9
• 10 year old girl• Abandoned by her mother• Staff said she confessed to being a witch • Steals, tells lies, beats up other children
• Mental State– Hears voices of several ‘unseen’ people talking about
her
Third ‘Witch’
Remand Home 2007
• Praying• Fasting• Exorcism (repeated)
• Many days children had to go without food as part of fasting exercise
• Had no contact with mental health workers prior to visit by our team
• Now have twice weekly outreach • Treat children and train staff• Macarthur Foundation has supported this work
Management of ‘Witchcraft’ by Staff in Remand Home
Psychosocial Issues – School Settings
Psychosocial Issues – School SettingsChildren in Primary Schools
Psychosocial Issues – School Settings
Psycho-social Issues - Adolescents
22%
Lack
22%
Academics
13%
Health & Body
“My father does not have money to educate me”
“I have to wear a torn uniform to school”
“I am worried about my final exams because I don’t go to any lesson at home”
“I don’t have time to read at home”
“My penis is smaller than my mates’ own” “The inequality of my breasts”
“My worry is that I will contact HIV/AIDS”
Psychosocial Issues – Adolescents
• Health – “The day I went to deliver my baby”,
• Armed robbers– “The day thieves came into our house and placed the gun on my
ear”
• Rioting– “It was during the Sharia riots in Kano”
What kind of trauma?
Psychosocial Issues – Adolescents
• Bad Dreams– “Because my aunty died on my birthday and I had a dream that
told me because of the date she died, I will also die”,
• Sexual assault – “Day I was deflowered by raping”
• Physical assault – ‘‘The day my grandmother stripped me naked and beat me for
something I did not do’
• Fire outbreak– “It was in my room when the curtain caught fire from the candle
lighted by my sister”
What is ‘Psychosocial’?
• In each of these contexts• Range of psychosocial issues are evident• Popularity of the term ‘Psychosocial’ has
increased tremendously in the last two decades• Use of this term also varies within the literature
Martikainen, Bartley and Lahelma, 2002
Psychosocial
Causes & Risks
OutcomesMediating & Context
Causes & Risks
Psychosocial Influences
Psychosocial risk factors
Psychosocial causality
Mediating factors
Psychosocial Support
Psychosocial Mechanism
Psychosocial Environment
Psychosocial Resources
Psychosocial
Context
Outcomes
Psychosocial Wellbeing
Psychosocial Distress
Psychosocial Health
PsychosocialDefinitions
• The influence of social factors on an individuals
mind, emotions, or behaviour• The interrelation of behavioural and social
factors• In the context of health, ‘psychosocial factors’
mediate the effects of larger social structural factors on individual health outcomes.
Martikainen, Bartley and Lahelma, 2002
PsychosocialUNICEF, The Office of the United Nations High
Commissioner for Refugees (UNHCR)
• Links between psychological and social processes• Continuous interaction between them and the
influence that each has on the other• ‘Mental Health and Psychosocial Support’ to
describe factors that: – Protect Psychosocial wellbeing– Promote Psychosocial wellbeing– Prevent mental disorder– Treat mental disorder
• http://www.unicef.org/protection/ http://www.unhcr.org/4c98a5169.pdf
Psychosocial Wellbeing
Emotions, feelings, thoughts memory,
attention and concentration,
thinking processes Behaviour
AffectiveCognitiveBehaviour
Social
Relationships, family,
community, culture, religion, economic status, schooling, living
environment
Omigbodun et al, [2008]
Psychosocial Wellbeing
• An Infant, Child or Adolescent enjoying psychosocial wellbeing has the social aspects impacting positively on the psychological experiences
• Although there are several overlapping areas the psychosocial issues at each stage would vary
Infants, Children, AdolescentsInfant• 0-12 months (United Nations) • 0 – 3 years (Zero to three, Infant Mental Health Task Force)
ChildUnited Nations Convention on the Rights of the Child
• Article 1 defines the holder of rights under the CRC as 'every human being below the age of 18 years unless under the law’
Adolescent• The United Nations define adolescents as individuals who
are 10-19 years old.• For several reasons, adolescence is difficult to define
precisely in many cultures
Infant Mental Health
WAIMH’s definition of Infant Mental Health captures succinctly the essence
• ‘the ability to develop physically, cognitively, & socially in a manner which allows infants to master the primary emotional tasks of early childhood without serious disruption caused by harmful life events.
• Because infants grow in a context of nurturing environments, infant mental health involves the psychological balance of the infant-family system’WAIMH Handbook of Infant Mental Health, volume 1, page
25 (1999)
Descriptions of Infant Mental HealthCore feature of Infant Mental Health
• Infant in context
– Focus of infant mental health has changed from the infant as an individual to an infant in context
– Effects of the infant and the environment are two directional
– Infant influences environment and the environment influences the infant (Sameroff, 2009)
– Environment is more likely to influence the infant than the other way round
Psychosocial Wellbeing of the InfantExample
• Very sadly, a mother died recently in a Hospital of post partum haemorrhage
• Leaving behind a set of twin boys• Everyone was devastated• Psychosocial exposure/risk factor• Immediate advice was to leave the babies in hospital
and decide what to do with them• Paediatrician not conscious or aware of the psychosocial
processes felt this was fine• Several weeks in hospital with the nurses on shift and
ward maids feeding the babies is fine at least they will get food to eat
Psychosocial Wellbeing of the Infant
• Infant health professional • Psychosocial mechanisms would determine
outcome• Extended time in hospital
– - lack of attachment– - psychosocial stimulation
• Awaken social networks to get surrogate mother • Psychosocial wellbeing
Psychosocial Wellbeing and Relationship to Mental Health in the
Child & Adolescent
The Mental Health Action plan of the World Health Organization 2013-2020, provides a definition of mental health
• Conceptualized as a state of well-being• Individual realizes his or her own abilities• Cope with the normal stresses of life • Can work productively and fruitfully• Able to make a contribution to his or her community
WHO, 2013
Psychosocial Wellbeing and Relationship to Mental Health in the
Child & Adolescent
• With respect to Children & Adolescents• Emphasis is placed on the developmental aspects• Having a positive sense of identity• Ability to manage thoughts, emotions• Ability to build social relationships• Aptitude to learn and to acquire an education• Ultimately enabling their full active participation in society
WHO, 2013
Psychosocial Wellbeing Agenda
Psychosocial issues run right through Convention of the Rights of Child
The Psychosocial Agenda
41 articles in Part One of the Rights of the Child
61%
25 have direct implications for the Psychosocial Wellbeing of the infant, child & adolescent
Policy, Services, Research &Training!!!!
The Psychosocial AgendaPromoting Psychosocial Wellbeing
Article Psychosocial/Mental Health ‘Rights’
3 Safe, healthy institutions with adequate & suitable staff
7 Cared for by parents
12 Be heard
13 Freedom of expression
14 Freedom of thought
17 Access to resources aimed at promoting mental health…..
18 Mentally healthy environments
27 Standard of living adequate for mental.. development
28 Primary education compulsory, available & free to all
29 Development of child's mental abilities to fullest potential
31 Rest & leisure
The Psychosocial AgendaProtecting
Article Psychosocial/Mental Health ‘Rights’ 9 Not separated from parents except in cases of abuse, neglect
19 Protect from all forms of physical or mental violence, injury or abuse, neglect
32 Protect from hazardous work harmful to health or physical, mental, development.
33 Protect from illicit use & trafficking of narcotic drugs & psychotropic substances
34 Protect from all forms of sexual exploitation & abuse
35 Prevent abduction, sale or traffic in children
36 Protect against all other forms of exploitation
37 Protected from torture, inhuman treatment or punishment
38 Do not take a direct part in hostilities
The Psychosocial AgendaTreatment
Article Psychosocial/Mental Health ‘Rights’ 24 Right of the child to enjoy the highest attainable standard
of health & to facilities for the treatment of illness & rehabilitation of health.
25 Right of the child who is receiving treatment for a physical or mental health disorder, to a periodic review of the treatment & all other circumstances relevant to the placement
The Psychosocial AgendaRehabilitation
Article Psychosocial/ Mental health ‘Rights’ 23 Children with mental & physical disabilities should enjoy a
full & decent life in conditions which ensure dignity, self-reliance & facilitate active participation
39 Appropriate measures to promote physical & psychological recovery & social reintegration of victims of neglect, exploitation, abuse; torture or armed conflicts
40 Those who commit crimes should be treated in a manner consistent with the promotion of the child's sense of dignity and worth
40 Facilities for counselling; probation; foster care; education & vocational training programmes & other alternatives to institutional care shall be available
Agenda for Psychosocial Wellbeing of Infants, Children & Adolescents
Training
Child Rights
PartnershipChild Rearing
PovertyMental health
Constitution
Centre for Child & Adolescent Mental Health (CAMH)
Training for CAMH - (2010)
CCAMH: Training for CAMH - 2015
CAMH Professionals in Africa - 2015
Outline
1. Identify Psychosocial Factors in Various Contexts of Care
2. Define and Describe ‘Psychosocial’ and Psychosocial Wellbeing
3. Descriptions of Mental Health & its Relationship to Psychosocial Wellbeing
4. Outline a Psychosocial Agenda
