The themes and subthemes of the findings are presented here in narrative form, according to the constructs of the Health System Dynamics framework, starting with Service Delivery. Direct quotations are added to illustrate key points.
Service delivery
Themes under this component will describe the structure of the CAMH system in the Amajuba District. This includes a general overview of CAMH services, and Identification and referral.
Overview of CAMH services
CAMH services in Amajuba District Municipality were diverse. Public sector professional mental health services were provided in a largely centralised fashion by psychologists based at the district regional hospital. This hospital served as a referral point for at-risk learners identified within the school system. Service providers who helped to identify and refer children and adolescents potentially requiring mental health care were situated at different levels of the community, health and education systems, and included nurses in clinics, social workers in the communities, educators, learner support agents and school health nurses in schools. Beyond the public health system, there were also a variety of non-government service providers who provided mental health services such as awareness campaigns, assessment and referrals to a limited degree. This included general practitioners, religious counsellors, non-governmental/non-profit organizations (NGOs/NPOs) and traditional healers.
In terms of the content of CAMH services, health care involved psychotherapy and psychopharmacological support, largely provided. Educators and caregivers mentioned additional interventions to assist children in the school environment and at home. Extra classes were organized for learners identified to be dealing with psychological challenges and struggling academically. They expressed that these interventions were insufficient and were negotiating for professional psychological assistance for the learners from the Department of Education. Further, the Department of Social Development provided disability grants to children with intellectual disabilities and autism, illustrated by the following:
"I was advised to register her for the disability grant from the government, so that helps cater for her needs. We are fine financially because she receives the grant." (Caregiver 4).
Identification and referral
A service that was described as especially problematic was early identification of CAMH problems and appropriate referral; with most CAMH conditions identified and referred by the school system – but were generally quite late in the illness progression, when they were affecting children's academic performances. Very few cases were identified by health workers in hospitals, PHC clinics, or by the caregivers. This finding was illustrated by the following:
"In most cases what I found is that children are identified by their educators. They are identified there in school and then referred to the clinic and then from the clinics to us here. And, there are few cases where children are brought to the Hospital for other things and mental health issues are picked up as a secondary problem that is seen, but otherwise in most cases it's the educators unless a child has a clear mental health issue that is visible then the child is brought into the health system by the caregiver." (Clinical Psychologist 1).
Once a child has been identified as needing mental health care, further steps depend on the specific space where identification occurred, and the nature of the perceived need. The educators and learning support agents (LSA) in schools mentioned that they provided some initial assessment and interventions before referring the children for further care. However, four of the twelve schools visited within the district still did not have any skilled staff or resources to provide initial CAMH assessment or interventions to assist their learners, they also did not have any information on the referral pathways. Integrated School Health Programme (ISHP) teams were yet to adopt mental healthcare into their activity portfolio.
"we identify learners who have special needs, behavioral problems or learners who are abused physically, emotionally and socially. Firstly, we screen those learners, fill the necessary forms and then we sit down with the learners to find out what the problem is, identify how we can help and if we cannot help, we call in supervisors from the DBE district office, then they will come and assist. They either do one-on-one sessions or sometimes they will take a group for assessment. After assessing them, if they see that the learners do have problems, they refer those learners to special schools. If it's a behavioral problem, they make sure that they do follow-up interventions like counselling or social work consultation and they refer some of the learners to the psychologists." (LSA, school C).
A principal mentioned the need to train educators to prevent inappropriate referral and labelling.
"….to take this matter seriously we need some resources to assist the schools, then the training of teachers also is important. I don't want teachers to wrongly identify and say it behaviour problem when the learner does not want to write due the relationships you have with that learner – so training of teachers is very important- so that they can be able to identify the learner." (Principal 1).
A senior mental health professional highlighted that the psychologists are mostly the first point of contact for children and adolescents with CAMH conditions within the hospital (most of the referrals from the schools are addressed to them) and they refer them to the appropriate specialists for cases in need of more specialized interventions. According to one of the psychologists:
"When they come to us, they are mostly accompanied by their caregivers, if maybe they come from school they come with their educators. So, we do the debriefing to sort of understand the child's condition and give us a picture of what is going on so that we can determine which services they need, and then if they need to be referred to other specialists, we do that. (Clinical Psychologist 1).
The psychologist also mentioned inappropriate referral from schools, children with learning disabilities that should be referred to educational psychologists are referred to the clinical psychologists. This is due to the shortage of educational psychologists in the district, thereby resulting in back referral.
"Children with learning difficulties are often referred to us but we always refer them back to the department of education because they have an educational psychologist. We understand that she is the only one for the district, and she's not coping. Because of this, schools tend to push them towards the department of health, but we don't do those assessments". (Clinical psychologist 1).
Resources
The availability and organization of CAMH resources in the district are presented below, according to human resources, infrastructure, and supplies, knowledge, and information.
Human resources
Participants described a severe shortage of human resources to deal with CAMH problems within the Departments of Health and Basic Education. The service providers within DoH mentioned that they are overwhelmed due to limited CAMH human resources, increasing CAMH workload and inadequate CAMH training for non-specialists.
"…it’s tiring and frustrating. Because sometimes the available resources are inadequate…although, Madadeni hospital started child psychiatry training for professional nurses. The first Nurse was trained last year and two professional nurses are currently undergoing training at Bloemfontein. I think they are still not enough considering the number of cases we see” (Psychiatric nurse 1).
There was a widely-held view that CAMH services are limited in the district, but there was also sympathy from several participants that the few service providers were doing their best, and – under the circumstances – purportedly provided highly responsive care. Caregivers were appreciative of the good communication and friendly engagement of key mental health professionals. This was illustrated by the quotation below:
“We got a very great help, they really helped us, especially the Provincial hospital... the services were very good, and they were very helpful. The medication he receives here is helping a lot. They communicate with me properly, I was even able to ask questions and they could answer, they have been very caring towards me and the child, so I can say it was very good.” (Caregiver 2).
The lack of mental health human resources, and the resulting limitations in providing care, was bemoaned by one mental health participant as follows:
Unfortunately, we can’t see them more than once a month like everyone else because of staff shortage. However, if there is an urgent need for treatment, like sometimes we do fear that these persons might do something to harm themselves then we try to squeeze them in, but we just see them once a month. We usually make appointments in the mornings for people to come and see us… However, for school going-children we do make provisions for them, we see them in the afternoons, we schedule their appointments for 2pm, so that at least they will be able to go to school in the morning.” (Psychologist 1).
Some medical professionals noted that CAMH services provided opportunities for self-development, as most of them are medically qualified professionals without formal qualifications in psychiatry or child and adolescent psychology.
“I enjoy providing CAMH services …it’s very interesting and challenging but I learn from the experience and it motivates me to develop my skills…I was working with a doctor who was about to retire so I joined her and she exposed me to one or two things before she left. I have some years of experience in it now, but I’m not a child and adolescent specialist, we don’t have any in the district as well.” (Medical officer 1).
The psychiatrist suggested that the CAMH system could be strengthened through the development of outreach teams to expand the CAMH workforce, ensure consistent in-service training across all the departments involved in delivering CAMH services, particularly for PHC nurses to facilitate the integration of CAMH services into primary health care, conduct awareness campaigns and provide psychosocial support to families to strengthen the existing CAMH system.
“I suggest the development of a Psychiatric Outreach Team consisting of professional Nurses, Staff Nurses and Social Workers. They need to go and visit Schools so that they can do in-service training and awareness campaigns…. visit families because they need to capacitate them and support them. Also, training, I have been yearning for this, the PHC Staff members should undergo CAMH training.” (Psychiatrist).
Infrastructure and supplies
Findings revealed that there were very few special schools catering for children with special needs in the district, and only two of them were equipped to admit children with CAMH conditions. An educator from one of the two schools stated that the school was overpopulated due to the increasing prevalence of CAMH in the district:
“At first, we had the capacity of 150, but due to the increasing number of children with mental disabilities we have about 350 leaners, our school is full.” (Educator 2, special school 1).
There was widespread concern about the challenge of finding suitable schools for children whose mental health needs could not be met by their current schools. Some children were not enrolled into school at all, because they were rejected by the mainstream schools, with the limited special schools available in the district being overwhelmed due to the lack of space and shortage of resources. A caregiver relates this as follows:
“I once struggled to find a school for him and I am still having that challenge because I am yet to find one that can accept him.” (Caregiver 7).
In cases where caregivers were successful in placing their children in special schools, they received additional support in the form of transport services, as described below:
“He is now studying in a special school, where they have trained teachers who are knowledgeable about his condition, so I am happy he is in the right place. They taught him how to write when he got there...he's now trying to write his name. It is just okay because they also provide him with transport.” (Caregiver 13).
The chief director of special schools from the district Department of Education explained the school placement procedure.
“First, we do the placement assessment, when a leaner is referred for special school placement. A committee which consist of an occupational therapist, physiotherapist, the HOD and the class teacher will sit to decide. We assess the physical ability of the child and then cognitive assessment all these assessments will assist us with class placement. You know, sometimes the learner comes to us at the age of 10 and never accessed any form of education, but we can’t place them in the first year of School. After series of assessments, once we realize the level of assistance needed by the learner, we then recommend placement, we will then ask the parents to sign a consent form where they would agree that the learner should be enrolled into a special school.” (Chief director, special schools).
A caregiver also voiced her concern about the lack of higher education or opportunities for career development for adolescents with mental disabilities.
“My worry is that when they reach the age of 18 they should not just stay home, there must be something for them to do because people take advantage of children in these kinds of conditionsbecause a lot of them tend to wonder in the street after they leave school. Maybe the government could help build a school that can take those that are over the age of 18.” (Caregiver 17).
Knowledge & information
There seemed to be a lack of knowledge in communities on identifying mental health symptoms at an early stage. In some cases, caregivers noticed some symptoms at an earlier stage, but they couldn’t specify the nature of condition and did not access care for the child until they were identified and referred from school. These caregivers also mentioned that they could not seek help for the children because they didn’t have a clear understanding of the conditions, where and how to seek medical care. This is illustrated below:
“I noticed before the school called me, but I couldn’t take any step because I didn’t know what the problem was and where to take him for treatment until he was referred by the school, they gave me a letter and I took her to the hospital.” (Caregiver 14).
Some caregivers reported that they noticed certain symptoms of abnormality. Although they couldn’t ascertain the nature of the problem, they immediately sought help for the child. Two of the caregivers took their children to the clinics close to them and were referred to the hospital while others took their children directly to the hospital. However, the caregivers who took their children directly to the hospital mentioned that they were requested to obtain referral letters from the school or a clinic. The following excerpt refers:
“We noticed the problem at home, but we couldn’t identify it as autism, so I brought him here to the hospital but then they said I should get a letter from his school about his condition.” (Caregiver 11).
Population
The results under this component reveal the characteristics of the CAMH service users mainly caregivers of children with CAMH challenges in the district.
Government stakeholders described particular challenges in engaging with caregivers of children and adolescents with mental health needs. Many caregivers were yet to accept their children’s conditions and struggled to comply with the prescribed treatment regimen, and highlighted below:
“I love working with the children but some of the caregiver are in denial they don’t adhere to what you tell them whether its homework, time keeping, bookkeeping. It’s kind of frustrating because you know the child should be improving, but the child is not because the parent or caregivers are not adhering.” (Psychologist 1).
The challenging nature of child and adolescent mental health conditions led to many of the caregivers describing feelings of concern, helplessness and exhaustion, as expressed below:
“I cried a lot and even now I haven’t accepted it because I have two children, both have same condition. I accepted with the first one, but I couldn’t accept with the second one. It was really hard, and people were talking all they want about me and making fun of me that they rejected my children from school.” (Caregiver 4).
The complicated nature and under-resourcing of CAMH conditions further have a substantially negative effect on educators, not to mention the critical weight such conditions have on children’s functioning, daily interactions with their environment, emotions, behaviors and academic performance, resulting in, among others, poor academic performance, school truancy and drop-out. The below quotation refers:
“Their conditions affect us a lot; particularly it makes me sad. It affects us to such an extent that we end up not knowing what to do because we encounter such problems each and every day and there is no way we can help the children. It also affects their academic performance many of them are not doing very well academically, and some of them exhibit some behavioral problems. sometimes we spend extra time to assist some of them, we visit their homes and even give some learners money to buy grocery.” (Educator 2).
Leadership and governance
Participants pointed to the lack of a coordinated system of CAMH care as a major barrier to providing and accessing CAMH services in the district. This was exemplified by, particularly, poor intersectoral collaboration, and the lack of a standardised procedure and coordination for delivering CAMH services across the various departments in the district. There were no adequately integrated procedures for managing and reporting CAMH cases.
One participant referred to the overall system of care for children living with CAMH conditions in the district as “disjointed”. An example of this disjointedness was that certain services were packaged for children in different age groups across the two hospitals, which often required caretakers to find means of transporting the children between the hospitals to access different specialist services. This is illustrated in the quotation below:
“The system is a bit disjointed, for children below 12 years, we still have to refer them to Newcastle hospital for occupational therapy and speech therapy. It would’ve been better if we had everything in one place, but for children above 12 years, it’s better because everything is here.” (Occupational therapist hospital A).
Context
Factors that were perceived to impede CAMH service provisioning from the wider contexts of the district emerged. The coalescence of the district disease burden and resource shortages resulted in very limited health awareness being conducted, which in turn resulted in poor mental health literacy. Tied to this barrier, it was often mentioned that there are high levels of stigma towards mental illness among children and adolescents, illustrated by the following:
“She does get discriminated which is something that pains me a lot. We are even afraid to send her to the shops and they even discriminate her because of the school she is going to.” (Caregiver 14).
Dysfunctional family systems were raised as a major risk factor and barrier to accessing CAMH services for children. The participants particularly emphasized the absence of parents - leaving children to the care of grandparents and other family members or leaving adolescents to care for themselves as a major problem in the community. The following quotation illustrates this point:
“…most are from broken families; they stay with elderly people and we’ve got children heading the family.” (Principal).
“Some of the parents are not staying with their children, they work and stay out of town… They come on month ends - just providing money - and leave the children to guide themselves. Some children are in distressful situations because they were in a way abandoned by their parents.” (SANCA coordinator).