INTRODUCTION
Although mental health services in Uganda have rapidly improved in the recent 5-6
years, child and adolescent mental health remained a very big challenge due to lack of
special attention to this branch of psychiatry.
The country with a population of about 31 million people, had one child and
adolescent psychiatrist (now retired) who was based in Kampala and unable to reach
out to the whole population.
And this was also worsened by children and adolescents with mental health problems
been admitted and nursed among adults in the only National Psychiatric Hospital
Butabika in the country.
Though mental health serves are been offered in regional hospitals, no special
attention had been paid to child and adolescent mental health services
However, a day children’s unit was opened in Butabika (The National referral Mental
Hospital) in 2006 by mental health professionals from East London and in 2010 an
inpatient ward was opened.
The East London trust in conjunction with Commonwealth developed a strategy to
develop specialised child and adolescent mental services to Uganda by training two
doctors, one psychiatric clinical officer and two nurses from UK who will be trainers
of other health professional in child and adolescent psychiatry.
Objectives
To gain knowledge and skills in:
1. Individualised patient care
2. Psychiatric diagnosis and/ or psychological problem identification
3. Use of medication, as and when required
In order to achieve the above objectives, I had a two months placement at Coborn
Centre for Adolescents which is an in-patient unit with a bed capacity of 12 in Acute
ward and 3 in the Intensive Care unit and it also has day care services.
During my placement at Coborn, I learnt how patients are assessed, either on
admission to hospital or at review meetings in the hospital and how it differs from
how assessments and care-plans are implemented in Uganda.
How care-plans are designed and implemented for each patient according to their
individual psychiatric, psychological, emotional and behavioural needs, at each stage
of their care.
How wards are managed, day services are programmed, school routines are
therapeutically programmed to promote the patients recovery.
This was done through different therapeutic approaches to care management by a
good multi-disciplinary team, care-programme approach to care plans, assessment and
treatment models according to each multi-disciplinary team, psychiatric emergencies,
nursing care plan, evaluation and documentary
To achieve these objectives, I had to review, reflect on how some of these skills,
techniques or structures might be applicable or adapted to the children’s unit and outpatient clinics at Butabika.
And also review and reflect on how to do this in practice, at Butabika, in relation to
the challenges, constraints and possible limitations, who to talk to, or to work
alongside with in order to implement the knowledge and skills that I have acquired.
Lessons learnt
From the above objectives, I have gained a reflective understanding of the journey
young people make through the acute phase of the illness, psychiatric intensive care
and day-patient services.
This is done through individualised care, care plan assessments meetings,
involvement of the families/ care takers in every step of care the young person goes
through and with the full consent of the parents/caretakers unlike in Uganda where we
have no care plan meetings and no structured care plan for the young people.
In Butabika, involvement of the parents/ caretakers depends on their availability as a
result we at times treat and discharge the young person without interacting with the
parents/caretakers. This is due to the poor referral system we have in Uganda making
it difficult to trace the young person’s family until after recovery as the young person
could have been abandoned near the hospital compound as child protection services
are also poor in Uganda unlike in UK where child protection is a very sensitive matter
and in case of any suspicion of child abuse, social services does thorough
investigations.
I observed how psychiatric assessments are done by psychiatrists and SHOs on
admission, it aims at getting a psychiatric diagnosis and possibly use of medication.
The assessment doesn’t differ so much from what we do in Uganda, but with
medication in UK, there’s minimal use of medication and very low doses which is
discussed during ward rounds and hand over meetings.
I also noticed the use of atypical anti-psychotics in very low doses unlike in Uganda
we use typical antipsychotics, very high doses and young people end up with extrapyramidal sides.
I gained a good understanding of how the multi-disciplinary team works together and
how each professional has a specific part to play, which contributes to the whole
functioning of the service and individual young person’s care management. This was
done through the different approaches to care and therapeutic management which
include

Care programme approach (CPA)

Assessment and treatment models according to each multi-disciplinary team

Psychiatric emergencies

Nursing care plans, evaluation and documentation

Care-plan and implementation from other disciplines including psychiatrists,
psychologists, occupational therapists, teachers, and family, therapists work
and differ from each other.
Experience at Child and Family Consultation Services at York House
At York house, community Child and Adolescent Mental Health Services (CAMHS)
are been offered by a well and specialised multi-disciplinary team. They do mental
health assessment and identify emotional and behavioural problems affecting children
and their families, and how the families, schools and communities have contributed
either positively or negatively to the development of this behaviour and how the
different stakeholders can be supported to help the young person either deal with or
cope with it. They work hand in hand with the different schools, families, social
service, GPs and the young persons. They support the family through taking therapy
unlike in Uganda where taking therapy is not much practised leading to use of
medication when at times is not necessary. In my placement at York House, I never
witnessed use of medication and the service users seem to be happy with it.
The different multi-disciplinary team have sub-groups, depending on their speciality
where they sit for filter and feedback meetings in order to allocate new cases, give
feedback on the young persons they have been following and close cases
Conference and workshops
I attended four major conferences and two workshops organised by Association of
child and Adolescent Mental Health (ACAMH) on:
Child and adolescent learning disabilities
Mental Health problems affecting asylum seeking children
Preventing mental health problems through very early intervention
Cognitive behavioural therapy (CBT) across cultures
During the conferences, I learnt that when mental health problems are prevented or
identified early in children, problems like learning disabilities, emotional and
behavioural problems would be minimised and the number of adults with psychosis or
mental health problems would be very low.
I also learnt children present with emotional and behavioural problems after having
physical, psychological and sexual which is inflicted on them by adults, however,
when they can no longer take it, then it’s seen in their behaviour.
They sometimes witness things that they find very scary or stressful, they react by
either fight or flight (fight by becoming child soldiers or flight by seeking asylum)
during which they go through many stressful events like sleeping in the wilderness,
feeling hungry, being physically and sexually abused and they later present with
different mental health problems which need intervention by mental health workers.
Uganda, having been in war for 20 years has children who were born during the war
and have never known what peace is like, they present with traumatic memories. They
may present with anger, sadness, guilt, horror, confusion and at times they may
present with psychosis and lack of trust for adults. As a result l feel taking therapy
would be the best for such depending on how they present.
Children who grow were there’s domestic violence, parents abuse drugs, unstable
relationships may end up with learning difficulties, emotional and behavioural
problems.
It may seem reasonable to expect early identification of problems in childhood to be
straight forward process but in practice, quite not been the case. While some cases are
not easily identified especially emotional abuse but physical abuse can easily be
identified as a result, there’s need to provide conducive environment for children.
This can be done through health education to parents and care takers on causes of
mental health problems, need for early intervention good child protection services,
and integration of mental health into Primary Health Care Services, which we have
started doing in our daily mental health care delivery in Uganda.

Implementation

A good child and adolescent mental health service can be delivered in Uganda,
this can be done through:

Specialists in child and adolescent mental health to train mental health
workers and other health professionals in how to identify, assess, and prevent
mental health problems. Butabika, Mbarara and Mulago being teaching
hospitals, NHS has trained two doctors, two nurses and one psychiatric
clinical officer strategically from this hospitals in child and adolescent mental
health services, and we plan to work as a team to implement it.

Planning structured programme for young people right from the time of
admission to time of discharge in order to promote their recovery, and need to
use more talking therapy than high doses of drugs

There’s need for individualised care as young people present differently with
different problems as a result there is need for care plan assessment for each
young person

I also realised it is very important to involve parents/caretakers in the care of
the young people as they go through their journey from the acute phase to day
care service

Prevention of mental health problems through very early intervention is a very
good measure. As a preventive measure, it will be necessary to make the
public aware of factors that can cause mental illness and mental health issues
and aware of possible ways of preventing them. In Uganda, we have been
trying to do this through health education to the communities but at times it is
complicated by cultural issues, as a result, Ministry of Health has encourage
health workers to work with traditional healers to reach to the communities.
Challenges

The ratios of patients to health care-providers is too high leading to healthcare
providers not having enough time with the young persons individually

The numbers of patients with epilepsy and learning disability outnumber the
number of people with mental health problems

Lack of specialists in Child and Adolescent mental health with inadequate
multi-disciplinary team leading to professionals being exhausted

Poor referral system leading to waste of time assessing patients who don’t
need mental health services, and this leads to overwhelming number of
patients.

Also due to the poor referral system young people are at times abandoned on
the hospital compound by relative/ caretakers or brought in after been found
by police loitering in towns and such patients at times fail to trace their homes
leading to congestion on the ward

Mental health services delivery in Uganda are at times affected by cultural
issues which makes people seek mental health services late, hence, delaying.

Due to poor resources, reaching out to the people who need services becomes
difficult
Way forward
There’s need to open a school for nurse, psychiatric clinical officers, occupational
therapists to specialist in child and adolescent psychiatry.
This is already in progress and we have just finished the draft syllabus with the
support from NHS Butabika link
Training all health professionals with knowledge, skills in identification, assessment,
prevention and management of mental health problems
Need to actively involve parents/caretakers in the care of the young persons with
mental health problems
To work with the hospital administration in order to implement good child and
adolescent mental health service delivery by designing a good referral system
especially for children and adolescents
There is need to start Uganda Association of Child and Adolescent Mental Health in
order to share with other professionals and improve services in Butabika in particular
and Uganda in general.
Summary
Mental health problems can be prevented or minimised if there is early intervention.
And identifying mental health problems in children and adolescents can reduce the
prevalence in adults. In Uganda, child and adolescent mental health remained a
challenge due to no special attention was paid to it. With the training of specialists in
this field of psychiatry by NHS East London, child and adolescent services in Uganda
will improve.