Why mental health and education cannot be separated
Attention-deficit/hyperactivity disorder (ADHD) has received increased scientific, clinical and public attention over the past few decades. ADHD is the most common psychiatric disorder in children – affecting 2.0% to 16.0% of the school-age population. However, in South Africa, data on prevalence rates, access to care, and treatment for ADHD is limited. Despite the known efficacy of treatment, access to health care and treatment remains limited for many children in South Africa. Untreated ADHD results in substantial costs and has a negative impact both on educational attainment and quality of life.
The Goldilocks and The Bear Foundation (www.gb4adhd.co.za) was founded in March 2017 and is operational since June 2017. The Foundation provides mental health screening and early intervention at school level for children in underprivileged communities in order to ensure early identification and intervention for mental health barriers to education.
We have recently completed a study (“Removing mental health barriers to education: a community project”) which has been presented at the South African Society of Psychiatrist’s national congress, and was also published in the South African Journal of Psychiatry (Schoeman, Enright, James, Vermeulen & De Beer, 2018). See https://sajp.org.za/index.php/sajp/article/view/1293/1253
Our study, spanning the first year of operation (June 2017 – May 2018) aimed to establish the prevalence of ADHD and the key characteristics of children referred to the Foundation for emotional or learning difficulties. Our study aimed to establish the prevalence of ADHD and the key characteristics of children referred to the Foundation for emotional or learning difficulties.
During this year, we have visited 17 schools and provided access to mental health screening and services to more than 12 000 children. However, some schools did not participate (two opted out, while three failed to complete the required documents). Five-hundred-and-sixty-one children were referred to us with possible learning difficulties (86%), behavioural problems (41%) or emotional difficulties such as anxiety or depression (33%). Most of these children were referred from the foundation phase (i.e. years 1 to 4 of schooling) with a mean age of 9 years (±2.83) years, ranging from 5 to 14 years. More than half of the children referred were boys. See figure 1.
Figure 1: Children referred for screening
Although the Department of Education requires that children should first be assessed and assisted by the School Based Support Team (SBST) prior to referral to the Foundation, 61% of the children were directly referred to us by teachers. This was mostly due to the SBST being non-functional in most of the schools which we’ve visited, but also due to the sheer overload of work (and paperwork) which the teachers are facing.
Twenty of the referred children (4.0%) were previously diagnosed with ADHD, while three-hundred-and-six children (55% of those referred to us) presented with ADHD, or symptoms suggestive thereof. See figure 2.
Figure 2: Children presenting with ADHD or symptoms suggestive thereof
We have referred 390 (69.52%) of the children for further evaluations to confirm diagnoses or to exclude other conditions which can “mimic” or accompany ADHD, while 57 (10%) of the children were referred back to the SBST without any intervention other than recommending didactic support and parental guidance. Unfortunately, many children did not arrive for their scheduled appointments (provided pro bono), as transport is problematic for a large part of the community (since then, we have been able to do more of these additional assessments at the schools, instead of children having to attend appointments for e.g. educational psychologists and occupational therapists at the volunteers’ offices). Our further assessments confirmed the presence of intellectual disability in 19 (3%), depression and/or anxiety in 42 (7%), and various sensory problems and developmental delays (which mimicked ADHD) in 81 (14%). Amongst the children we assessed, 221 (2.5%) were struggling with ADHD. We have also identified 34 (6%) who were subjected to abuse. These children were subsequently referred to the Departments of Health, Education and Social Development for further management. See figure 3.
Figure 3: Further evaluations and referrals of children
Lower than international prevalence rates of ADHD may reflect a lack of awareness of the disorder, misconceptions about the disorder in the community with regard to mental health disorders and treatment, and stigma. As most of the children referred to us were in their foundation phase of schooling, it is possible that many of the children in the higher grades may also be struggling with ADHD and other mental health disorders but were not referred. Due to the workload of the teachers, some of them opt not to refer any children. There was also a tendency to refer children which fulfil the “classical” picture the public has of ADHD: a naughty, hyperactive boy, while the silent “daydreamers” and girls, are often not identified.
Although mental health clinics exist in the public sector, children with ADHD often never reach this point of diagnosis and treatment. It is so important that children with learning difficulties are identified early – before they develop self-esteem problems, mental health problems, or behavioural problems. Although medication plays and important role in the treatment in some of these children, behavioural interventions, and educational and emotional support are also crucial.
The Goldilocks and the Bear Foundation aims to highlight the need to address mental health barriers to education through screening and early intervention. The results from our study highlights the need to raise awareness and reduce stigma, and can also be used to plan future service delivery. Collaboration between (and with) the Departments of Health, Education, and Social Development, are crucial to reduce, and remove, mental health barriers to education.
Acknowledgements: Gratitude is extended to the Friends of the Foundation and our volunteer health care professionals for their financial and support and assistance with service delivery