The plight of social workers working with children and adolescents suffering mental health disorders in South Africa

doi:10.21203/rs.3.rs-1781769/v1

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Research Article

The plight of social workers working with children and adolescents suffering mental health disorders in South Africa

https://doi.org/10.21203/rs.3.rs-1781769/v1

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Social workers working with children and adolescents displaying mental health disorders in the Child and Youth Care Centres (CYCCs) have an enormous responsibility to support and care for these young people. In under-resourced countries such as South Africa, their responsibility includes educating caregivers on how to better manage the conditions of these young people and to support them with behavioural changes. This responsibility is however, not free from hindrances such as a lack of relevant resources. Despite the significant role played by these social workers and their challenges in supporting these young persons, research attention is very limited in this field of social work practice. This stillness impelled an exploratory qualitative research study aiming to explore the challenges faced by social workers when rendering services to these children and adolescents. The study was conducted in South Africa’s Gauteng province, designed from exploratory and descriptive strategies and following ecological systems theory. The data collection method used was semi-structured online interviews and the collected data was analysed through Braun and Clarke’s six steps of qualitative data analysis. In ensuring data verification, the trustworthiness strategies proposed by Guba and Lincoln were adopted. The findings are presented in four themes: the general challenges of working with child and adolescent mental health disorders, the service-related challenges, challenges of dealing with complex disorders and limited resources for child and adolescent mental health disorders. Among the recommendations proposed is the design of research-based programmes to assist social workers working with case of children and adolescents with mental health disorders.

Social workers

Children

Adolescents

Mental health

disorders

Qualitative

Child and adolescent mental health (CAMH) disorders are prevalent in up to 20% of children and adolescents across the globe [1, 2, 3). The manifestation of these disorders happens during very important developmental phase of their lives, which is often characterised by changing cognition and development of mental wellbeing and skills with the potential to impact their future as adults. Children’s life circumstances have an enormous impact on their mental and physical health and adverse events heighten their risk of mental health disorders [4]. Mental health disorders negatively affect a child’s wellbeing and their actions, relationships, ability to deal with stressors and decision-making skills [5].

In Africa, CAMH disorders cause an overwhelming strain and most countries do not have access to proper mental health services [6]. The Sub-Saharan African data on CAMH disorders reveals its occurrence in 14.5% of children and adolescents below the age of 16 [7]. Despite these high figures, there is no evidence of mental health policies in several African countries [6, 8]. Africa also lacks sufficient studies on CAMH disorders and related challenges [9, 10]. This is despite an undeniable link between research and policy, and their significance in creating scientifically informed policies to positively impact the lives of CAMH disorders [11]. It was insufficient scientific literature in CAMH disorders and the interlink between research and policy that impelled researchers to conduct an exploratory and descriptive study of the challenges confronting social workers working with CAMH disorders in South Africa’s CYCCs.

THE STATUS OF CAMH IN SOUTH AFRICA

The South African status of CAMH disorders is unclear because studies usually comprise small and incongruous samples, with diagnostic measures not accounting for the country’s unique context [12, 13]. Children and adolescents in South Africa are confronted by harsh and challenging conditions [13], with research revealing adverse events heightening their risk of mental health disorders [14, 4]. However, when exposure to adverse experiences declines, mental health disorders and associated challenges get reduced [14]. In responding to these challenges, South Africa developed intervention strategies like the National Child and Adolescent Mental Health Policy Framework of 2003 and the National Mental Health Policy Framework and Strategic Plan 2013-2020 aiming to propel provincial policies on child and adolescents mental health [15, 16, 13]. However, the implementation pace of these policies at the grassroots level is concerning, with no evidence thereof in any of the country’s nine provinces [17]. Furthermore, mental health programmes for children and adolescents are also concerning in South Africa, where there is no evidence of procedures and protocols for CAMH disorders [19]. The implication is that intervention strategies that are currently designed and implemented may not have scientific basis.

THE SIGNIFICANCE OF SOCIAL WORK IN CAMH

The need for policies and programmes to guide interventions across South Africa’s provinces will depend on the active involvement of professionals like social workers whose primary responsibilities include safeguarding and promoting social justice among the marginalised population groups such as CAMH disorders. The role of social workers in CAMH is of significance. They bring change by creatively and distinctively responding to challenges faced by individuals, families, groups, organisations and communities by building on their strengths and competencies[20]. Furthermore, social workers are on the frontline in addressing adverse experiences and their impacts on families and children. Whenever challenges present themselves, social workers intervene and support [21]. Their services are essential for mental health care because they safeguard and advocate for the needs of people facing mental health-related challenges [22]. The distinctiveness of social workers lies in their ability to find possibilities that are ingrained and linked to the daily experiences of people with mental health disorders. Due to their ability to blend tangible services for mental health support with the collective experiences shared in the client’s environment, social workers can achieve a more sustainable intervention [23]. Despite the crucial role of social workers, there is scanty of literature concerning the challenges faced by social workers working with CAMH disorders in CYCCs [24]. It was this scanty of literature that impelled researchers to conduct this study.

THE THEORETICAL FRAMEWORK UNDERLYING THE STUDY

The ecological systems theory (EST) is central to social work. From the EST perspective, social challenges are comprehensive. They include societal systems that can either address or aggravate such challenges. The theory comprehends intricacies of these challenges by propelling social workers to find solutions or opportunities when societies place limitations on its people [25]. The EST is based on three significant features which are:

People evolve by actively influencing their environments. They are not simply affected or controlled by their environments;
An exchange takes place between people and their environments which requires some kind of compromise.
There is more than one influential system connected to a developmental environment encompassing interrelations between different environments and how they are impacted by the broader milieus [26].

Considering the aforementioned, CAMH disorders in CYCCs are therefore not only affected by the system in which they find themselves; they also affect such systems. Certain compromises are being made within the child’s exchanges and their relationships. Understanding these compromises and what they are could bring a better understanding of the child or adolescents experiences.

Lastly, the centre is not a secluded environment, it is influenced by a variety of environments outside it such as schools, a child’s extended family, hospitals etc. A long waiting list at a hospital or an incorrect school placement will undoubtedly have an impact on the child, social worker and the CYCC as a whole. Interventions to address the challenges in any of these systems should have an extensive focus. The EST is suitable when dealing with CAMH disorders because efforts towards this area should spread beyond the scope of mental health practice to include programmes and support in education, communities and broader society if it is to have a meaningful impact [18]. It is an EST approach to child and mental health considers various determinants of mental health disorders and developmental liabilities with the potential for lifelong impact and that childhood and adolescence are filled with developmental liabilities that are impacted by the environment and life events with lasting influence on mental health into adulthood [27]. This necessitates a comprehensive understanding of this field from the EST.

The four environmental classifications of the EST are the microsystem, the mesosystem, the exosystem, and the macrosystem [26, 28, 25, 29]. Notably, children and adolescents form the basis of all these systems [28]. The microsystem of a child or adolescent is facets of their environment that exert an influence on their daily lives and they include their family, educators and peers [28]. In the context of this study, the microsystem will include a child or adolescent and their interactions with their house parents, peers, schools and any other important persons in their lives. Social workers would also logically involve themselves in this system and the interactions that children and adolescents have in this system.

The mesosystem comprises of two or more microsystems [26, 28, 29]. In the mesosystem, the social worker would consider the benefits and adversities of the person’s relationships within their systems [25]. The mesosystem for CAMH disorders in the centre would involve for example the collaboration between the CYCCs and the school. It focuses on discovering how various systems influence and interrelate with the CAMH disorders and the social worker respectively and how they support or puts pressure on the system. The exosystem is where a person is not functionally participating but where incidents occur that impact the person and their immediate environment [26, 28, 29]. In this context, the exosystem means events within the CYCC that had an unintended or unforeseen effect on CAMH disorders. They may include a high caseload or turnover of social workers and the likely effect on CAMH disorders. The macrosystem involves culture, traditions, religion, morals and beliefs with an indirect influence on all of the different systems [26, 29]. It is essential to comprehensively understand the challenges faced by social workers working with CAMH from their own perspective by paying attention to the broader context such as the effects of policy and legislation and the misconceptions around the subject.

RESEARCH SITE, POPULATION AND SAMPLING

This study was conducted in Gauteng province among social workers who were employed in nongovernmental CYCCs and who were rendering services to CAMH disorders, who had been placed in these centres. The study population was social workers who were rendering services to CAMH disorders in the CYCCs. Purposive sampling was used to recruit participants who were willing and able to share the challenges associated with working with CAMH disorders. For participants to qualify for selection, they had to be (i) a registered social worker employed in nongovernmental CYCC; (ii) rendering services to children and adolescents who were suffering from mental health disorders; and (iii) the organisation under which social workers were serving had to be within Gauteng province.

An exploratory, descriptive and contextually designed qualitative research approach was adopted for this study. Whereas an exploratory design is used to gather information about a group of people or an occurrence for which little information is available, descriptive design is used to describe such a group of people or an occurrence in detail, [30]. Contextual design is used to provide information based on the context of the research area [31]. Researchers wanted to explore and describe the challenges faced by social workers working with CAMH disorders in the context of CYCCs from their own viewpoint. It was also important to collect data specifically about mental health disorders in the centres environment as it is a unique environment with its own set of dynamics.

Due to the COVID-19 pandemic, semi-structured-online interviews aided by an interview guide were used to collect the data. The interview guide contained seven open-ended questions to enable participants to share their challenges freely in their own words and at their own pace. Online interviews are becoming popular because of pioneering technologies like Skype and Zoom and therefore provides researchers with options to enlarge their research population and not limit themselves by geographical constraints and therefore appropriate due to their expressive and communicative features [32, 33]. Braun and Clarke’s six steps of qualitative data analysis were used for data analysis while Guba and Lincoln’s trustworthiness criteria of credibility, transferability, dependability and confirmability guided the data verification process [34, 35]. Whereas Credibility, transferability and dependability were heightened through prolonged engagement with the participants, triangulation, peer debriefing and thick description, confirmability was enhanced through an audit trail [35]. On the ethical front, the study was cleared by the University of South Africa’s College of Human Sciences Research Ethics Review Committee (Ref. No: 2020-CHS -10353542), with ethical principles of informed consent, anonymity, confidentiality and data management observed throughout the research process.

RESEARCH FINDINGS

The findings of this study are in the form of biographical information of the participants and the main research findings which are presented in the form of themes and subthemes. This manuscript focuses on four of the seven themes that emerged from the process of analysis.

Findings on the biographical profiles of the participants

Nine female social workers participated in this study and their ages ranged between 24 and 60. Of the nine, seven had a bachelor’s degree in social work and two had a master’s degree in social work. Regarding social work experience in mental health, five participants had between two to three years, three ranged between five and ten years and one participant had 23 years of experience. Their caseloads varied between twenty-two and thirty-six, with only one with a caseload of 60 cases. Their caseloads were compliant with Department of Social Development (DSD) norms and standards which stipulate that an individual social worker should not have more than sixty cases [35].

Theme 1: Insufficient support for social workers working with CAMH disorders

When asked about availability of support for them, participants reported lack of funding and long waiting periods, lack of knowledge of CAMH among people and their lack of training around CAMH disorders.

Subtheme 1.1: Lack of funds and long waiting periods

Participants reported lack of funding and long waiting periods when seeking services for their clients as a challenge.

Linda had this to say regarding lack of funds:

“…there is really a lack of finances for the children to receive the correct help that they need… …”

In her narration regarding limited funds, Ida said:

“…it comes back to the funds because DSD [Department of Social Development] is only subsidising fifty per cent each month…”.

In our interview with Laura, she reported challenges relating to long waiting periods:

“Well, we have to use government hospitals and in the government hospitals there’s very long waiting

queues…”.

Alice was frustrated by the time it took to access the necessary services:

“Time, you know, they take time to help our children…I’m sitting here with a child…who is suicidal, but I cannot get help…”.

Lack of funds and long waiting periods illustrate budgeting difficulties for mental health in South Africa. South African studies of the mental health gap revealed mental health funding challenges such as lack of services and budgets both at national and provincial level of government [37, 38]. Generally, long waiting periods are not uncommon in South Africa, where people depend on governmental facilities and hospitals for services [38].

Subtheme 1.2: Lack of knowledge around CAMH disorders

From the narratives of the participants, it emerged that people’s lack of knowledge around CAMH disorders poses a challenge to them.

Laura explained how lack of knowledge among people leaves patients labelled and judged:

“…People lack knowledge on mental health. If you do mention mental health issues…...,

people quickly withdraw because the term mental health issue is still a very judged or labelled issue…”.

Dorothy also told researchers how people lack information:

“I think people don’t have enough information. They hear a word mental health and then they make their own opinion, their own stuff around this but not necessarily remembering what it’s actually about…”.

A lack of knowledge around mental health disorders confirms the findings by others wherein people’s lack of knowledge was seen as a potential cause of misconceptions, stigmatisation and labelling [39]. A South African study focusing on CAMH services revealed how lack of knowledge result in stigma which is the main reason for misperceptions, judgement and bias [39]. Stigmatisation and misconceptions fall within the macrosystem of the EST which impacts on children and social workers who are confronted by CAMH disorders in CYCCs. The macrosystem entails culture, traditions, religion, morals and beliefs bringing regularity to other systems by indirectly influencing them [26, 27]. An important part of social work is advocating by among others, addressing misconceptions and stigma [22].

Subtheme 1.2: Lack of training on CAMH disorders among social workers

A lack of training among social workers on how to manage CAMH disorders was also common, with participants like Lucy reporting as follows:

“…we are not trained to look after these children at all…We need more trained social workers who can deal with this condition…”.

There also seemed to be hesitancy on the part of participants to conduct counselling with CAMH disorders as some felt it was not in their scope of practice. Ida narrated:

“And I also think, the children with mental health problems, I am not that qualified to give them the effective therapy…”

Dorothy also shared similar experiences:

“I think, with mental case…we sometimes feel as social workers we are not skilled, that’s why we can’t do the therapy. But actually, we can do the therapy. I think we just scared… I think we are [skilled], but we just lack some self-confidence…”.

Participants’ narratives regarding lack of training, confirmed the findings made by some researchers, where one of the reasons social workers lack knowledge on CAMH disorders was due to the failure of social work training to devote attention to mental health [10, 40]. CAMH disorders are central to social work and social workers need proper skills and training to effectively respond. This reflects how the microsystem consider a person's daily tasks, functions and reciprocal relationships as most significant for successful management of CAMH disorders to avoid additional strain and negative impact on the broader system [26, 29].

Theme 2: Managing complex CAMH disorders

When asked about challenges experienced with complex mental health cases, the responses shared by the participants gave rise to three subthemes outlined below.

Subtheme 3.1: The impact of complex cases on house parents

Participants spoke about the impact of CAMH disorders on house parents and their challenges in supporting fatigued, exasperated and sometimes traumatised house parents.

Alice had this to share:

“Mostly we are seated now with house parents who are drained, who are emotionally drained…Because they do not have the means, the knowledge, to help the children…So we sit with frustrated house mothers who come to us as professionals and say, I don’t know what to do…”.

Linda related as follows:

“The impact is very negative. The house parents really struggle to handle these types of… incidents. Emotionally they are just drained, and they don’t know which way to go anymore…”.

The need for training, knowledge and skills among house parents was evident from Ida who said:

“I think the house parents have the most influence on these children…I think they also need to be trained. They also need to be equipped with the necessary skills... …”.

House parents face challenging behaviour displayed by CAMH disorders in their care because these young people need support and care with consistency and dedication, something which is difficult for these parents [42]. Part of the social workers’ role is to support children and their house parents. When house parents are able to manage CAMH disorders in the houses, social workers’ efforts in managing challenging behaviour will be strengthened. The opposite is eminent when house parents are not properly equipped, resulting in a challenged caregiver-child relationship. A residential care study found that there is validation of strong and nurturing connections between CAMH and their house parents [43]. A child’s connection to his/her houseparent is linked to their health and wellness [49]. The house parent-child relationship and its impact on the social worker and CYCC system can also be fathomed from the EST, through which the CYCC can be considered a system with a shared goal wherein people work together to meet this goal and deliver services to children in their care. Systems are made up of subsystems that rely on one another and in the CYCC, these subsystems are social workers, house parents, children and others necessitating an understanding of the challenges and how all subsystems influence each other [26].

Subtheme 3.2: Extreme mental health disorders affect other children

As with the impact on the house parents, the data revealed how exposure to outbursts and severe behaviour, affect other children in the CYCCs. A further concern was how exposure to incidents re-traumatised CAMH disorders.

Amy described how other children were afraid and how their fear triggered their own mental health challenges:

“Some of the children are just plain scared of the child and won’t go near them. It fills them with so much anxiety to be in the same house as the child because they fear, they kind of fear for their own lives.

Ida mentioned how copying and mimicking behaviour could have an accumulating effect and cause long-term challenges for exposed children:

“Because most of the time, when we leave it too long, the other children start to adapt those behaviours. So, then we are sitting with a bigger problem at the end of the day…”.

A study conducted in an African orphanage revealed how exposure to outbursts and violence in the CYCC has an enormous impact on children [45]. Sometimes this impact is even greater than what they’ve been exposed to before coming to the centre. Furthermore, a strong link between their experiences of violence and the negative conduct displayed by CAMH disorders reaffirmed how experiences influence a child’s health, conduct and development. Exposure to brutality in any form can affect a child’s ability to form connections, cause mental health disorders, conduct problems and harmful perceptions [46]. It can therefore be argued that this type of exposure in a child’s microsystem will cause severe disruptions within this system and other systems and therefore necessitate social work intervention.

Subtheme 3.3:Disciplining challenging behaviour of CAMH disorders

From the participants’ narratives, a subtheme emerged pertaining to the challenge of disciplining children who display challenging behaviour and aggressive outbursts.

Dorothy attested to this:

“…she had this very aggressive behaviour and it was like she was an animal, a wild animal. And it’s like if she’s zoned out. You can speak to her but it’s like she’s not present…”.

Laura shared challenges with a child with managing conduct disorder:

“…But as he is getting older, he’s stronger so he’s starting to try and hit us or bite us or throw us with stones or things like that. So, getting him into the office can be difficult…”.

In another interview, Alice reported a sense of helplessness:

“…Because our children, you know, they are mentally challenged. They end up having uncontrollable behaviour…we cannot control that behaviour. We end up not knowing how to deal with it.”.

Although some researchers are positive about the role of social workers in supporting CAMH disorders through various methods and techniques, there is inconsistency regarding the plans and strategies for dealing with extreme conduct challenges and in supporting children with special needs [23]. It is the connection between social workers and CAMH disorders that can bring change [47]. The significance of relationships within the systems is central to the EST [28]. This relationship has the potential to bring hope and improve stressful environment.

Theme 4: Inaccessible resources for CAMH disorders

During the interviews with the participants, multiple challenges were mentioned, some of which related to medical and psychological resources; schools; institutions; plans, programmes. Despite the challenges, the data also revealed that some resources were available, though needed to be strengthened.

In an interview with Amy, she said:

“At Steve Biko, there is two psychologists, that see the children and they evaluate them and then you have to take the child back. I don’t know how many times. I think it is at least three or four times for the evaluation and then they get referred to a psychiatrist…”.

Ida shared her challenges as follows:

“…we have, firstly, a lot of children with severe diagnosis that…there is no form of other support available to us. For example, we only have Weskoppies, which is a psychiatric hospital. There [are] only one or two doctors, so we are on waiting lists…the children are on waiting lists for three or four months…”.

Participants also felt that children were unnecessarily placed on medication. Maria attested:

“I think they try to cope, but it is very, very difficult. It’s really difficult and at that stage, because there’s no resources, it’s always... and increasing [in] the medication…”

According to Amy, medication was used to manage these children because other resources were not accessible:

“I feel medication is used as a quick fix because we don’t have therapy readily available and I also think that influences the child. So, I would like if medication could be our last resort instead of our first…”.

It is clear from the narratives that CAMH disorders and their social workers face many obstacles when accessing mental health services from hospitals. South-African studies [19,12] attested to this by pointing to CAMH disorder services that are underprovided and ineffective. A South African analysis of CAMH disorder services found a limited number of psychiatrists dedicated to CAMH disorders [39]. Scarcity of resources and ineffective dispersal of care and support for CAMH disorders in schools, welfare organisations and healthcare centres were also common [39]. Due to a lack of CAMH facilities, the admission of children younger than 12 years with mental health challenges to children’s ward was a challenge, with older children with mental health issues placed in adult mental health wards not set up for supporting and managing CAMH disorders or protecting children [25]. Regarding medication, social workers play a crucial role in assisting clients with their medication often by making choices of medication and treatment for children, which is a daunting task.

Child and adolescent mental health disorders remain a global challenge, with the African country still battling with its containment. Although it demonstrated some commitment to address the scourge of CAMH disorders by putting policies in place, South Africa still grapples with the challenges associated with CAMH disorders. Although the appointment of social workers was envisaged to mitigate against this challenge, this study has revealed that they themselves become victims of the challenges posed by CAMH by among others, having to work with limited resources and lacking proper training to respond to some of the extreme challenges associated with these disorders. Apart from having to deal with CAMH disorders themselves, social workers also deal with house mothers who also face difficulties in managing some of these CAMH disorders. The society is also found not to be supportive to these professionals who often find themselves exposed to people with misconceptions due to lack of knowledge and the difficulties of having access to services from hospitals and schools that are meant to be supportive. As propagated by the EST, addressing these challenges will not only require an intervention only in the source of its manifestation, but a broader focus on all systems within which it manifest such as the immediate houses where these young people interact with house parents, to the schools and within the CYCCs where they interact with other children. Interventions will also have to be directed to the broader society, communities and other sectors with the overall aim of ensuring that support is extended to CAMH disorders either through simple advocacy or lobbying for support.

Given the findings, it is recommended that:

advocacy and other educational programmes be designed and implemented by social workers to educate communities about mental health and the significance of supporting victims thereof;
mental health be mainstreamed in the schools by developing mental health-related programmes to enable accommodation of CAMH disorders in order to eliminate their exclusion from the mainstream schools;
programmes for supporting social workers and house parents dealing with CAMH in with the CYCCs be developed and implemented in the CYCC;
mental health be incorporated as part of social work curriculum to equip social workers from as early as first year of study;
social workers lobby government and funders to provide resources and funding of mental health programmes.

ACKNOWLEDGEMENTS

Authors wish to acknowledge the funding support received for this project from the University of South Africa Post-graduate Study Assistance.

CONFLICT OF INTERESTS

The authors wish to declare that there is no conflict of interests whatsoever to be reported.

FUNDING OR SOURCES OF SUPPORT

This was a Master’s study funded through the University of South Africa’s Post-graduate Study Assistance.

AUTHOR CONTRIBUTION

Ms Candice Lee Jacobs

All authors wrote the main text of manuscript. Ms Jacobs wrote the introduction and presented the findings. Dr Lekganyane wrote the preliminary literature sections and conducted literature control. Furthermore, Dr Lekganyane formatted the manuscript according to the journal requirements and ensured coherence. The two worked together to search for literature to support the findings. Although Ms Jacobs did set the base for the manuscript through the introduction and literature review, Dr Lekganyane was instrumental in interrogating the data using existing literature and in compiling the conclusion of the manuscript. At the final stage of the manuscript, Ms Jacobs had to read through the entire manuscript to ensure that is readable.

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No competing interests reported.

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The plight of social workers working with children and adolescents suffering mental health disorders in South Africa

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Abstract

Introduction And Background

Research Methods And Ethics

Conclusion

Recommendations For Social Work Practice, Training And Research

Declarations

References

Competing Interests

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