CHILD AND ADOLESCENT MENTAL HEALTH POLICY GUIDELINES

Ministry of Health, Uganda

March 2017

Acknowledgements

Dr. Sheila Ndyanabangi, PMO, MOH; Dr Hafsa Lukwata, SMO, MOH, Dr Basangwa David, Executive Director, Senior

consultant Psychiatrist, Butabika Hospital, Dr. Joyce Nalugya, C&A psychiatrist, CAMH program director, MNRH, Dr.

Godfrey Zari Rukundo, C&A psychiatrist, CAMH program director, MUST, Dr. Juliet Nakku, DED, Adult psychiatrist,

Butabika Hospital, Dr Birabwa Harriet, Senior Consultant Psychiatrist; Dr. Angela Akol, Health systems, Researcher,

Dr. Julius Muron, Adult psychiatrist, Butabika Hospital, Dr. Brian Mutamba, Adult psychiatrist, Butabika Hospital,

Dr. Sylvia Nshemerirwe Psychiatrist, Butabika Hospital, Dr. Abbo Catherine, C&A Psychiatrist, Makerere University,

Dr. Jannet Nakiggudde, Clinical Psychologist, Makerere University, Dr. Jacintha Kabeega, C&A Psychiatrist, Kabale

Hospital, MS Joy Gumisiriza , Clinical Psychologist MUK, Mr James Nsereko – Clinical Psychologist Butabika

Hospital, Mr. Elias Byaruhanga, PPCO, MRRH, CAMH specialist, Mr. Thomas Walunguba, PPCO, Moroto RRH, CAMH

specialist, Mr. Samuel Kimbowa , Occupational therapist, Butabika Hospital and CAMH specialist, Ms Syson

Katushabe, CAMH specialist social worker, MUST, Ms Jane Martha Akullo, CAMH specialist PCO,Jinja RRH, Ms

Margaret Ocokoru, Principal PCO school, Butabika, Mr. Patrick Otim, CAMH specialistPCO, Naguru Hospital, Mr.

Richard Stephen Mpango, CAMH specialist OT, Clinical Psychologist, Ms Joy Nkurunziiza, CAMH trainee, MNRH, Ms

Florence Aleuziyo, CAMH specialist PCO, Butabika Hospital, Ms Patience Butesi MOH, Ms Murengezi Grace, Policy

consultant, Agnes Bulega- Ministry of Gender Labour and Social Development, Paul Ahura – THET Uganda, Paul

Senteza- Sign Health Uganda, Joseph Walugembe – ADD Uganda, Medi Sengooba – Disability Rights Fund, Patric

Owaga– Uganda Children Rights NGO Network (UCRNN), Angela Nsimbi- My Story and Dr Alyson Hall – UK

Coordinator CAMH Uganda training Project.

Special thanks to World Vision Uganda for supporting the first draft; The Tropical Health Education Trust (THET) for

supporting the completion of this work

Foreword

The Child and Adolescent Mental Health Policy Guidelines are designed to promote Mental Health and prevent Mental, Neurological and Substance use disorders among children and adolescents. These guidelines are a statement by the Government of Uganda to set a clear direction in development of Mental, Neurological and Substance abuse control services and as such, aim to ensure that these services are readily accessible to all children and adolescents in Uganda. The Policy Guidelines represent the views and recommendations of a wide range of stakeholders across government sectors, civil society, private sector, adolescents and the general public.

The Policy recognizes that the burden and impact of Mental, Neurological and Substance abuse (MNS) disorders on young people and the community is big and the burden is growing. In line with this, the guidelines outline ways of promoting the mental wellbeing of the Ugandan children and adolescents. It also provides strategies for reducing the incidence of these disorders and their impact on the lives and well-being of children and adolescents.

The key strategies for effective Mental Health promotion and prevention of MNS disorders adopted by these guidelines will enhance engagement of communities to increase their participation, build capacity of human resources across sectors to increase availability and access to MNS services by children and adolescents. The guidelines also emphasize the need for strengthened coordination, collaboration and partnerships among different stakeholders at all levels of care for children and adolescents at risk and those already affected by MNS disorders. The guidelines call for the review and or the enforcement of existing laws and policies for promotion of mental wellbeing of children and adolescents. Lastly they promote research, monitoring and evaluation of MNS services for children throughout the Country.

These Policy guidelines are in line with International and National laws, policies and regulations for Mental Health in children and adolescents including but not limited to the sustainable development goals (SDGs), the UN Convention on Rights of Children, the National Health Policy, the National Development Plan, the Uganda children act and the National Mental Health policy. These guidelines provide a framework upon which all stakeholders should organize and deliver MNS services for children and adolescents in the next 10 years. It is envisaged that the strategies in this guidelines will result in a significant improvement in the prevention of MNS disorders, treatment, care and quality of life of all children and adolescents in Uganda.

Dr. Henry G. Mwebesa For: Director General Health Services

Contents

Foreword ......................................................................................................................................... 1

LIST OF ACRONYMNS ...................................................................................................................... 3

GLOSSARY ........................................................................................................................................ 4

1.1 INTRODUCTION AND BACKGROUND ........................................................................................ 5

2.0 Situational Analysis ................................................................................................................... 6 2.1 Burden of MNS Disorders among children and adolescents .............................................................. 6

2.2 Availability and Access to MNS services ............................................................................................. 8

2.3 Laws, policies and regulations for Mental Health in children and adolescents ................................. 9

2.4 Research, monitoring and evaluation ............................................................................................... 10

2.5 Coordination, collaboration and partnerships .................................................................................. 10

SCOPE OF THE CHILD AND ADOLESCENT MENTAL HEALTH AND MNS DISORDERS POLICY GUIDELINES ................................................................................................................................... 10

3.0 THE POLICY OBJECTIVES .......................................................................................................... 10 VISION ..................................................................................................................................................... 10

MISSION .................................................................................................................................................. 11

GOAL: ...................................................................................................................................................... 11

OBJECTIVES ............................................................................................................................................. 11

4.0 STRATEGIES. ........................................................................................................................... 11 Objective 1: ............................................................................................................................................. 11

Objective 2: ............................................................................................................................................. 13

Objective 3: ............................................................................................................................................. 14

Objective 4: ............................................................................................................................................. 15

Objective 5: ............................................................................................................................................. 16

Dissemination strategy .................................................................................................................. 17 6.0 Roles and Responsibilities ...................................................................................................... 18

7.0 Monitoring and Evaluation ..................................................................................................... 23

8.0 Service standards .................................................................................................................... 23

REFERENCES: ............................................................................................................................ 27

LIST OF ACRONYMNS

ADHD Attention Deficit Hyperactivity Disorder CAMH Child and Adolescent Mental Health CDO Community Development Officer DALYs Disability Adjusted Life Years HMIS Health Management Information Systems SDGs Sustainable Development Goals MNS Mental, Neurological and Substance Use Disorders NCDs Non Communicable Diseases NGOs Non Governmental Organisations UPE Universal Primary Education USE Universal Secondary education WHR World Health Report WHO World Health Organisation YLDs Years Lived with Disabilities

GLOSSARY

Mental Health is “a state of emotional and psychological well-being in which an individual is able to use his or her cognitive and emotional capabilities, function in society, and meet the ordinary demands of everyday life.’’(WHO) Child and adolescent Mental Health is the capacity to achieve and maintain optimal psychological functioning and wellbeing. It is directly related to the level reached and competence achieved in psychological and social functioning. (American Academy of Child and Adolescent Psychiatry (2002) Child - A person below the age of 18 years (UN Convention on the rights of children) Adolescent- A person aged 10 to 19 years (WHO) Adolescence is a time of tremendous emotional upheaval and change. It refers to the transitional developmental period between childhood and adulthood and to a maturational mental process involving major physical, psychological, cognitive and social transformations (ref) Mental Health Programme: A logical sequence of pre formulated interventions for the promotion of Mental Health, prevention of mental disorders, and treatment and rehabilitation. Mental Health stakeholders: Persons and organizations with some interest in improving the Mental Health of a population. They include Mental Health service users, family members, professionals, policy makers, funders and other interested parties. Mental illness: a disorder diagnosed according to the classification system of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Disease, 10th edition (ICD 10) Mental, Neurological and Substance use disorders: A group of disorders including but not limited to depressive disorders, anxiety disorders, schizophrenia, bipolar disorder, Autism

Spectrum disorders, learning disorders, intellectual disability, childhood behavioral disorders, eating disorders, epilepsy and substance use disorders (alcohol and illicit drugs)

1.1 INTRODUCTION AND BACKGROUND

Children and adolescents are vulnerable to certain specific Mental, Neurological and Substance use

disorders due to their incomplete physical, mental and social growth and development (1). Children

affected by mental and neurological problems such as epilepsy, are less likely to be well integrated

into school and other developmental programs (2). As a result, children affected by these conditions

are less likely to develop their full potential and are less likely to live a productive adult life (3). On

the other hand, children and adolescents affected by drug abuse and excess alcohol consumption

experience disrupted social and mental growth and development.

Globally, about 20% of children and adolescents experience Mental Health problems. As a result of

these problems, the sufferers miss opportunities and can experience long lasting consequences (4,

5). The Mental Health problems interfere with their ability to participate in education, relationships

and work. When no appropriate intervention is put in place, these Mental Health problems continue

into adulthood (6). The Mental Health burden is higher among the poor, the vulnerable and those

with other disabilities (7). Furthermore, most children and adolescents with Mental Health problems

are in the low and middle income countries (LMIC) (8) and unfortunately, most of these problems

are not recognized and therefore misdiagnosed and many go untreated (9-11).

In Uganda, about 57% of the population is contributed to by children and adolescents (12) yet their

Mental Health needs largely go unmet, with severe and often irreversible consequences for their

emotional and psychological development. Many of the Ugandan children have experienced

psychological trauma during war, abductions as child soldiers, physical or sexual abuse and

bereavement, especially from AIDS, poverty and increasing disparities (13-15).

Although there is such a great need for child and adolescent Mental Health services, there are

no guidelines for planning child and adolescent Mental Health services, training and

collaborations with other partners.

Children and adolescents tend to underutilize mental, neurological and substance use health services due to several factors including:

1. The organization of health services in the Country not being sensitive to the needs of children and adolescents with MNS.

2. Children can only seek Mental Health care and treatment through their parents; yet parents may have different perceptions about the child’s behaviour or illness. Early signs of distress are often missed or mismanaged.

3. The public has limited knowledge and awareness on mental, neurological and substance use disorders in children.

4. There is inadequate availability and limited access to quality MNS services country wide

In order to address these gaps; these Policy Guidelines provide a comprehensive approach to

scaling availability and increase accessibility of quality MNS services as well as providing a

framework for the promotion of Mental Health of children and adolescents in different settings.

2.0 Situational Analysis

2.1 Burden of MNS Disorders among children and adolescents

Child and adolescent Mental Health is a key public health issue underpinning the wellbeing of the child population, the development to healthy adults and the prevention of mental illnesses. The WHO Child and Adolescent Mental Health Atlas (2005) stipulated that countries with the highest proportion of children in the world lack both Mental Health policies and MNS services to address the needs of children and adolescents. In Uganda, demographic data showed that children under 15 years of age are a significant proportion of Uganda’s population, 16,898,000 (49.7%); and of these 337960, (2%) children are living with some form of disability (UBOS, 2014,

UNICEF, 2014). For most low income countries (LICs), the Mental Health needs of children and adolescents largely go unmet, with severe and often irreversible consequences for children’s emotional, behavioural and cognitive development. The Health Management Information Systems (HMIS) indicate low identification and attendance for treatment of such diseases and epilepsy compared with the prevalence estimated at 1-2% (MoH Reports 2012).

Various studies have indicated high prevalence rates of psychiatric disorders that range between 12% and 29% among children visiting primary care facilities in various countries (16). Only 10%–22% of these cases were recognized by primary health workers, which implies that the vast majority of children and adolescents did not receive appropriate services. Currently available epidemiological data suggest a worldwide prevalence of child and adolescent mental disorders of approximately 20%. Of these 4 to 6% are in need of a clinical intervention for an observed significant mental disorder such as suicidal attempts and ideation. which is the 3rd leading cause of death among adolescents(17). According to the World health organization, depression has been found to be one of the leading causes of disability as measured by YLDs and the 4th leading contributor to the global burden of disease (DALYs) in 2000. By the year 2020, depression is projected to reach 2nd place of the ranking of DALYs calculated for all ages, both sexes. Currently, depression is the 2nd cause of DALYs in the age category 15-44 years for both sexes combined (17).

In Uganda the burden of MNS disorders in children and adolescents has been increased by the effects of war, exposure to violence including defilement, poverty, physical, emotional and sexual abuse, commercial sex and sex for survival, addiction to substances such as alcohol and cannabis, infection or being affected by HIV/AIDS and other diseases like malaria resulting in psychological and/or intellectual handicap, bereavement and separation. Children affected by these factors have an increased risk of developing Mental Health problems. Epilepsy is common and it is often complicated by stigma, and delayed access to treatment. Without treatment it may cause brain damage and additional accidental injuries. The consequences of MNS disorders include; reduced ability to participate in education, relationships and work, both in childhood as well as in adult life. Failure to address MNS needs of children and adolescents may derail attainment of some SDGs targets such as universal access to quality education (Goal 4), abuse and neglect (Goal 16) bridging the gender disparity, poverty reduction and reduction of mortality in infants and mothers giving birth(18).

Studies in Uganda have indicated the high burden of child and adolescent MNS disorders. For example Nalugya et al, in a study of depression amongst adolescents in secondary schools in Uganda found a prevalence of depressive symptoms at 21% (19) while James Okello and colleagues found that depression symptoms mediated the association between stressful war events and multiple risk behaviors (20). The prevalence of anxiety disorders was found to be as high as 26.6%, with rates higher in females (29.7%) than in males (23.1%) (21) and adolescent suicidality in Uganda is high (22).

Alcohol and drug abuse in children and adolescents in Uganda is on the increase although not well researched. A study on substance use found a prevalence of 12.6% for tobacco use and 6.6% for alcohol use among 13 to 15 year old adolescents attending schools in six African countries Uganda inclusive (23, 24). The role of peer influence and parental under-supervision have been noted by Basangwa (1994), and further documented by other studies (25)

Conduct disorder related behaviors tend to persist into adolescence and adult life through drug and alcohol abuse, juvenile delinquency, adult crime, antisocial behavior, marital problems, poor employee relations, unemployment, interpersonal problems, and poor physical health. These have been studied to some extent in Uganda with a clearer cultural understanding among children affected by war (26). Scott (2002) demonstrated increased costs for care to society in later years from failing to recognise and treat early childhood conduct disorder. Leibson (2001) showed that over a nine year period the median medical costs for children with ADHD were $4,306.00 compared with $1,944.00 for children without ADHD. The costs are due to higher rates of admission to hospital emergency and outpatient departments and visits to primary care physicians. The study excluded the costs of treatment by psychiatrists and Mental Health professionals.

Malaria, HIV and orphanage have contributed significantly to the high burden of MNS Uganda. Cerebral malaria has been associated with occurrence of Mental Health disorders in children especially learning disability and Autism children (27), possibly as a consequence of ischemic neural injury. Musisi et al found considerable psychological problems and the presence of major psychiatric disorders HIV/AIDS infected adolescents (28, 29).

2.2 Availability and Access to MNS services

Mental Health services have not yet received the prominence and prioritization it deserves in health planning and dispensing of resources for health programs. Mental Health receives 0.7% of health spending in Uganda, with few Mental Health professionals outside Referral Hospitals. One third of the population live below the poverty line (WHO 2005) and the birth-rate is very high. Health records indicate that few children and adolescents with MNS Disorders attend adult Mental Health clinics where they are treated with medication. Psychological treatments, family therapy, and other specialized first line treatments for children, are almost unavailable or inaccessible.

During times of disasters and in trauma affected regions, NGOs often focus on specialized areas of interest, such as, child abuse, but do not provide for the total psycho social needs of the children and adolescents and where they try, these services are not sustainable by the affected communities. There is a great need for ethical guidelines to address the appropriate use and potential abuse of psychopharmacological medications with children. It is recognized that there are limited indications for the use of psychotropic medications in most children and adolescents. It is now well documented that there is stigma at all levels of society associated with children and adolescents with Mental Health problems and mental illnesses, and ironically with those providing for the treatment of those with these problems. There is a need to support ongoing campaigns to reduce stigma not just as a social exercise, but directly as it relates to access to care and support for building a continuum of care.

Primary health care workers, including physicians, have a very limited understanding of current concepts of diagnosis and treatment of mental disorders in children and adolescents. A study showed that 10%–22% of cases with psychiatric disorders among children were recognized by primary health workers, which implies that the vast majority of children and adolescents did not receive appropriate services. This hinders the ability to provide appropriate services to this age group and may add to the stigma of mental disorders in these young people.

Hence, it is a priority to obtain and disseminate current knowledge in a usable form to practitioners and policy makers. Pediatricians and other primary care workers must be given increased literacy about child mental disorders in their training to reduce misconceptions about the effectiveness and feasibility of care. Primary care based quality improvement programs for depression have been shown to improve the quality of care, satisfaction with care health outcomes, functioning, economic productivity, and household wealth at a reasonable cost.

In Uganda there is a great reliance on parents to provide care for their mentally ill or intellectually disabled child. This is often a time consuming and emotionally draining experience. It must be considered in developing systems of care that provisions be made for “respite care” to allow parental/ family providers to continue to work outside the home, engage in the normal range of family activities, provide for the appropriate care of other family members and regain their energy.

2.3 Laws, policies and regulations for Mental Health in children and adolescents

Despite its post-colonial turbulence, Uganda has in the last 25 years been peaceful, stable and democratizing its political systems. The Government runs public service delivery through a decentralized system where districts form program implementation units. This has enabled services to be tailored to the local needs of the community and it has also enabled the communities to participate in program implementation. The Government of Uganda is committed to the welfare, development and participation of children and youth in development. By scaling up UPE, USE and liberalizing University education, it has ensured that many children and youth access education and develop their potential. It has further demonstrated support to youth programs by allocating funding for youth training and employment needs.

In terms of legislation that address aspects of child and Adolescent welfare; the Constitution of the Republic of Uganda (1995) recognizes special needs of children and provides for access to treatment for all people. Uganda ratified the UN Convention on Rights of Children (1989), which emphasizes nondiscrimination, best interest of a child, right to survival and development and respect for the views of the child. Uganda signed the African Charter on the Rights and Welfare of the Child (1990) which among others notes with concern that the situation of most African children remains critical due to the unique factors of their socio-economic, cultural, traditional and developmental circumstances. Natural disasters, armed conflicts, exploitation and hunger, also impact on children’s physical and mental immaturity thus the need for special safeguards and care.

The charter recognises that the child occupies a unique and privileged position in the African society and that for the full and harmonious development of their personality, the child should grow up in a family environment in an atmosphere of happiness, love and understanding. In addition, the charter recognises that the child, due to the needs of his/her physical and mental development requires particular care with regard to health, physical, mental, moral and social development, and requires legal protection in conditions of freedom, dignity and security.

Uganda subsequently developed the Children’s Act 1997. The Children’s Act (1997) recognizes that children experience difficult life situations including parenting problems, child abuse and neglect, entry into care homes and foster parenting. The Act also provides for examination of children when entering into foster care but doesn’t provide for other reasons requiring examination such as when experiencing some forms of difficult social circumstances. The Children’s act was amended in 2016 to comprehensively provide for full rights of the child, introduce protection of Children from harmful customary practices (e.g. child marriage, FGM/C) as well as penalties for offenders, protect children from harmful employment, from violence and provides a right to access child protection services.

The above law provides for regulations to ensure that rights of children are respected and violations of child rights get reported and managed. In that respect, it gives roles to the community members, Local Councils, Secretary of children’s affairs in the Local Council, the police, Family and Children’s Court in the district, social welfare and probation officers.

In addition the National Youth Councils Act 1993 states that there is need to develop youth’s social, economic, cultural and political skills for participation in development. It defines the administrative structures to ensure that youth participate in these development programs. Mental Health, prevention of substance abuse and prevention of brain disorders among youth is critical to that process of development. The youth leadership structure provides a resource that can be used to organize child and adolescent Mental Health services.

Although the United Nations high level meeting on Non Communicable Diseases included Mental Health as a risk factor for prevention and control of NCDs it did not highlight the plight of children and adolescents with Mental Health problems and this may result in their missing out on opportunities for equitable access to effective programs and health care interventions.

2.4 Research, monitoring and evaluation

Research in child and adolescent Mental Health in Uganda needs to be improved and monitoring tools adapted to the Ugandan situation. Further there is need to strengthen the mechanisms to coordinate research in this area and to ensure that priority research questions are answered.

2.5 Coordination, collaboration and partnerships

The mechanism for coordinated action, multi-sectoral collaboration and intra-sectoral coordination in child and adolescent Mental Health issues are very weak. The leadership structures need to be strengthened for Mental Health promotion, particularly in children and adolescents.

SCOPE OF THE CHILD AND ADOLESCENT MENTAL HEALTH AND MNS DISORDERS POLICY GUIDELINES

These guidelines are national and multi-sectoral. The guidelines aim to address the needs of children and adolescents with MNS Disorders as well as promote Mental Health and prevent mental, neurological and substance use disorders. These policy guidelines will greatly contribute to protection of children from violence and abuse. They will also promote child growth, development and productivity in adult life. The guidelines were developed in the context of the Sustainable Development Goals, the Uganda National Development Plan and Vision 2040, national health policy, local government regulations and child related laws and policies in Uganda. Through these guidelines, delivery of MNS services will maximize use of existing Government structures and use of decentralized governance. The guidelines are meant for use by all government sectors and civil society stakeholders for a period of 10 years following adoption by government.

3.0 THE POLICY OBJECTIVES

The objectives of these guidelines are derived from the broad objectives of the National MNS Policy, National Health Policy and the National Development Plan and Vision 2040.

VISION

A country where all children are mentally well and performing to their full potential

MISSION

To promote mental wellbeing, prevent Mental Neurological and Substance Use problems and

provide quality, multi-sectoral and evidence based services that are equitable and appropriately

delivered at all levels of care for children and adolescents in Uganda.

GOAL:

To reduce the burden of MNS problems and improve the quality of life of children and adolescents affected by MNS Disorders.

OBJECTIVES

The specific objectives of these policy guidelines are:

1. To increase knowledge , understanding and involvement of policy makers, service

providers, families , community leaders and other stake holders for the promotion of

Mental Health and prevention of mental, neurological and substance use disorders in

children and adolescents;

2. To build capacity, improve access and availability of comprehensive Mental Neurological

and Substance use services for care and treatment of children and adolescents affected by

them including psychological treatment and rehabilitation of such children;

3. To strengthen research, Monitoring and Evaluation of child and adolescent MNS issues;

4. To inform the development and review of policies and legislation relating to child and

adolescent Mental Neurological and substance use issues;

5. To strengthen multi-sectoral collaboration and participation in providing quality child and

adolescent Mental Neurological and Substance use services.

4.0 STRATEGIES.

Objective 1:

To increase knowledge, understanding and involvement of policy makers, service providers, families, community leaders and other stake holders for promotion of Mental Health and prevention of mental neurological and substance use disorders in children and adolescents

SWOT ANALYSIS

Strengths:

1. Available health structure at all levels including community level

2. Availability of trained health workers in Mental Health

Weaknesses:

1. Weak laws concerning advertising by traditional healers, beer companies, etc

2. Poor enforcement of available laws

3. Mental Neurological and Substance use problems not a priority area for many

government sectors

Opportunities:

Sustainable development goals focus on Children and Adolescents and Mental Neurological and

substance use disorders

1. Many development partners working with children and adolescents

2. Willing stakeholders for collaboration

3. Availability of different media accessible in various parts of the country

4. Wide use of technology in Uganda

Threats:

1. Large child and adolescent population in Uganda

2. Political instability in some areas of Uganda and neighboring countries

3. Weakening family and social support structures

4. Negative cultural beliefs and practices about Child and Adolescent Mental Neurological

and Substance use issues

5. Inadequate resources

STRATEGIES

1. To develop and implement multi-media campaigns to raise awareness about mental

neurological and substance issues by involving all stakeholders including children and

adolescents.

2. Sensitize families , teachers and other adults close to children and adolescents about the

risk factors, symptoms and complications/consequences of Mental Neurological and

Substance use problems

3. Advocate for availability of inclusive education programs for vulnerable children and

adolescents and develop specific programs targeting children and adolescents at risk of

developing Mental Neurological and Substance use problems and those who already have

MNS disorders including pregnant adolescents, sex workers, homeless

4. Develop appropriate communication programs and guidelines that promote mental

wellbeing of children and adolescents in disaster, conflict or crisis situations and in the

general communities to protect them against/from abuse

5. Support faith based organizations, Non-Governmental Organizations, community based

organizations, user groups and other partners in implementing mental, neurological and

substance use programs for children and adolescents

6. Advocate for inclusion of child and adolescent Mental Neurological and Substance use

issues in the school curricula and other educational programs

7. Develop and disseminate information materials on child and adolescent mental neurological

and substance use issues to relevant stakeholders

Objective 2:

To build capacity, improve access and availability of comprehensive Mental Neurological and

substance use services for care and treatment of children and adolescents affected including

psychological treatment and rehabilitation of such children.

SWOT ANALYSIS

Strengths:

1. Existing child and adolescent Mental Health component in all health workers training

curriculum

2. Existing capacity building programme offered by a university and accredited by the

National Council for Higher Education (NICHE)

3. Availability of child and adolescent Mental Health personnel in all regions of the

country

4. Collaboration between training institutions, other stakeholders and Ministry of Health

5. The existing health service structure in all regions

Weaknesses:

1. Inadequate funding for the Child and adolescent Mental Health training programme

2. Poor access to services

1. Health workers have inadequate knowledge and poor attitudes about child and

adolescent mental neurological and substance use issues

2. Few opportunities for specialist career progression for nurses, psychiatric clinical

officers, psychologists and other professionals

3. Uncoordinated/ uneven deployment of Mental Health workers

Opportunities:

1. Locally available trainers

2. Collaborators willing to offer support

3. Sustainable development goals focus on capacity building

Threats:

1. Brain drain

2. Competing government priorities

STRATEGIES:

1. To train, recruit, deploy, supervise and retain, skilled personnel at all levels of health

service delivery and other institutions where children and adolescents access services

2. To strengthen child and adolescent Mental neurological and substance use services at

all levels of health care

3. Sensitization of community health workers to identify, refer and follow up children

and adolescents with mental neurological and substance use issues and sensitize

managers of health facilities and districts to plan for services targeting such problems

in children and adolescents

4. To establish mental neurological and substance use services in schools and other

institutions where children and adolescents are cared for

5. Strengthen community and family participation in the care for children and

adolescents with MNS

6. Strengthening community systems and their linkages to institutions that will promote

and support children and adolescents with MNS

Objective 3:

To strengthen research, Monitoring and Evaluation of child and adolescent MNS issues SWOT Strengths: 1. Different government sectors have Monitoring and Evaluation departments 2. Universities and other institutions are actively engaged in research 3. Some data about mental neurological and substance use issues is already being collected

from some regional referral hospitals through the Child and Adolescent Mental Health (CAMH) training program

Weaknesses:

1. Weak inter-sectoral collaborating and sharing of information Opportunities: 1. Global funding opportunities/Calls for proposals 2. Availability of data in various research institutions/programs

Threats:

1. Changing priorities of donors

Objective 4:

To develop and review policies and existing legislation relating to child and adolescent MNS

issues

SWOT Strengths: Uganda has ratified all the international conventions and charters for children and adolescents; e.g. UN convention on rights of a Children Weaknesses

1. implementation of laws is generally weak 2. Poor dissemination of policies and laws

Opportunities

1. Increased awareness on child and adolescent related matters 2. Sectors are fairly equipped 3. Mental Health part of the sustainable development goals 4. Presence of a department for children at the Ministry of Gender 5. Information

Threats 1. Stigma of MNS 2. Competing priorities

Uganda has many policies and laws promoting Child and Adolescent Mental Health. However, there is lack of awareness and understanding about the implication of the laws and therefore implementation is weak. There are several gaps in the laws necessitating their review.

Strategies

Government shall undertake the following strategies:

Develop, review and operationalize policies and laws concerning children and adolescents, and ensure their enforcement

Establish an appropriate dissemination mechanism to ensure that policies and laws are understood and enforced by all stake holders

Objective 5:

To strengthen multi-sectoral collaboration and participation in providing quality child and

adolescent MNS services

SWOT Analysis Strengths

1. There are many government departments with children’s desks 2. Many NGOs are getting interested and wish to promote children’s mental health 3. There are various actors providing child and adolescent Mental, Neurological and

Substance use services.

Weaknesses 1. Poor coordination due to lack of multi-sectoral approach 2. Poor funding (small resource envelope) 3. Services are fragmented and not comprehensive.

Opportunities 1. Representation of different sectors and agencies at district/lower levels which can

implement services e.g. community development office at even sub county level, child and family protection units

2. Presence of the public private partnerships policy Threats

1. Children with MNS have unique needs including need for equipment for promotion of development and learning, and special schools,

2. infrastructure and programs needed for rehabilitation of children with special needs e.g. street children and children in need of care, child mothers, juvenile offenders, child headed households require resources that may not be available at all levels.

Strategies:

1. Strengthen multi-sectoral collaboration and participation through establishment of child and adolescent MNS working groups at national and district levels

2. Develop standards for providing MNS services for children and adolescents at different levels of care

3. Develop an M&E framework and plan for MNS services

5.0 IMPLEMENTATION ARRANGEMENT

The policy guidelines will be implemented according to the Health Sector Strategic Plan (HSSP) frame work; integrated to primary health care, supported by referral system, multi-sectoral

collaboration and public private partnerships. The roles of key stakeholders are outlined in a matrix below.

Dissemination strategy

The Guidelines will be disseminated through a multisectoral coordination forum that brings together all stakeholders identified in the stakeholder matrix. Multimedia programs will be used to disseminate the guidelines

6.0 Roles and Responsibilities

The stakeholders across government and other sectors and the roles of the key stakeholders are listed in the table below.

Stakeholders Roles and responsibilities

Ministry of Health

Review the Mental Health policy

Develop protocols for screening for MNS problems in children and adolescents.

Develop clinical guidelines for interventions for children and adolescents with MNS problems.

Train Health Workers in management of MNS Disorders.

Develop a system of Monitoring & Evaluation of services within schools and other institutions providing care to children.

In collaboration with relevant Ministries and Institutions, ministry shall strengthen and expand training of all health care providers in the field of child and adolescent MNS care.

Liaise with curricula development Institutions/ agencies to include child and adolescent MNS issues in the training curricula of health workers and other practitioners in touch with children and adolescents.

Provide technical assistance for the design and implementation of Child and adolescent MNS programs that are sensitive to gender, age, culture and religion including children in conflict, disasters situations or children experiencing crisis. Coordinate and monitor and evaluate child and adolescent MNS programs of all Ministries and Agencies in the country.

Establish a coordination mechanism for child and adolescent MNS Services at National and District level.

Expand and extend coverage and scope of child and adolescent MNS service delivery by increasing the numbers of health units with community based distribution and social marketing systems.

Integrate child and adolescent MNS services at all levels of care.

Mobilize and allocate resources for MNS Services for children and adolescents.

Ministry of health will revise the HMIS tools to include disaggregation by age for children under 5, 6-10, and 11-24.

Support supervision tools will capture data on child and adolescent Mental Health and MNS Disorders.

Health Inspectors record and report on compliance with school programming and school environment

Police Educate police officers In laws of child protection and care of children affected by MNS disorders

Sensitize communities on laws on child protection

Strengthen and enforce the laws including protection of children from abuse

Collect, analyse and disseminate trends of offences related to child protection and care of children with MNS Disorders

Train DLG law enforcement officers on child related laws

Collaborate with international partners to manage cross border protection of children including those affected by MNS Disorders

Maintain records and manage information on children related offences

Community supervision of people with child related offending behavior in collaboration with other stakeholders

Link children in need of MNS services to health care services

Enforce the integration of children into their families

Expeditiously investigate and dispose of child related offences

Strengthen collaboration with other sectors to promote rehabilitation and resettlement of children affected by MNS Disorders.

Police record and disaggregate data in child related offences

Prisons Educate and train prison officers on child related offences

Sensitise prisoners at all levels to laws related to child protection

Ensure that children at detention centres access rehabilitation and they are not exposed to harmful environment for growth and development

Integrate released child offenders into their communities

Ministry of Justice

Create court environment suitable to children during court process

Sensitize public on child protection laws

Prioritize disposal of child related cases

Recruit and increase the number of judicial officers to handle child related offences

Cabinet Ratify international and national protocols and domesticate for MNS

Prioritize child and adolescent Mental Health in allocation of resources.

PARLIAMENT Review and enact laws to protect children.

Prioritize child and adolescent Mental Health in allocation of resources

Strengthen laws to safe guard children from accessing alcohol and drugs of abuse

Ministry of internal affairs

Communicate declaration of criminal behavior related to child offences to other stakeholders in order to protect

Disseminate laws on child protection and care to all NGOs working with children during registration and supervise to ensure compliance with the laws to protect children

Safe guard children from accessing small firearms

Ministry of information and National

Create an environment to enable communication of information for child and adolescent Mental Health issues

Restrict children’s access to harmful information and materials

Guidance Regulate, capture and share information concerning harmful messages to children and youth

Ministry of ICT Create an environment to enable communication of information for child and adolescent Mental Health issues including electronic health education

Restrict children from access to harmful information and materials

Regulate, capture and share information concerning harmful messages to children and youth

Ministry Gender, Labour and Ssocial Development of

Sensitize communities on child growth and development, child protection, parenting,

Educate and train CDO, Probation officers, child rights advocates, child protection committees.

Monitor and supervise children’s homes and institutions to ensure a conducive environment for promotion of mental wellbeing and prevention of MNS Disorders

Regulate home and institutions handling children with MNS Disorders

Provide facilities and programs for care and rehabilitation of children with in vulnerability, crisis, and incarceration.

Coordinate programs for care and rehabilitation of children and youth in the community

Maintain and share information on children under guardianship and adoption

Develop programs in community to promote mental and physical growth and development of children and adolescents

In collaboration with local government, to develop regulations and guidelines for management of public places and recreation centres targeting children and adolescents

Develop regulation for proper parenting and placement of children to family environment for proper care.

Coordinate protection of children from child labour and develop regulations for implementation of the policy.

Develop regulations for FGM Act, to protect girl children. In addition to collaboration with other stakeholders, use youth structures to mobilize and coordinate MNS Services in the community.

Ministry of Education and sports

Integrate issues of child Mental Health and prevention of MNS Disorders in school programs and curricula at all levels and genders

Develop life skills based training programs for children with MNS Disorders.

Create and supervise school environment for promotion of development of Mental Health of children including appropriate screening for MNS disorders.

Train personnel to advocate and monitor implementation of programs for readmission of children with MNS and other disorders back to school

Foster linkages between teachers, peers, parents, health workers and communities to promote mental wellbeing

Coordinate and evaluate programs for child safety and security in schools and institute measures for conflict resolution

Mobilise, allocate and monitor efficient use of resources for CAMHS in schools including special needs education.

To provide programs for education and training of children that are sensitive to their age, gender and disabilities including MNS Disorders

Ministry of Local Government

Local governments to develop bi-laws to create an environment conducive for child growth, development and prevention of MNS disorders

Local governments and police record and report on compliance with by-laws.

Recruit and retain CDO, probation officers, health workers

Establish facilities and programs for care and rehabilitation of children with MNS Disorders

Enforce child protection laws and regulations in partnership with other stakeholders

Identify and allocate resources for MNS services for CAMH

Plan, coordinate and provide effective and accountable leadership to meet the needs for CAMHS; participation of all stakeholders

Prioritize and monitor CAMHS

Mobilize communities to participate in CAMHS in collaboration with other stakeholders

Integrate CAMHS in all relevant departments at operational level

Build capacity for delivery of child and adolescent friendly MNS services

Monitor and evaluate MNS Services in the district

Collect and report data on MNS disorders and MNS services for children and adolescents

Ensure that roles are shared and implemented at all levels of l-Local government.

Ministry of Public Service

Incorporating child & adolescent cadres into public service system to promote their participation in service delivery.

Development of schemes of work and recruitment of child and adolescent service cadres

Ministry of Finance

Identify and Allocate funds for implementation of child related Mental Neurological and Substance use Services.

Monitor management of funds

Ministry of Defense

Protect children from war related trauma

Prevent child recruitment

Educate and train security officers on MNS Disorders and care of children

Treat children with MNS Conditions in war settings

Designate an officer in-charge of children with special needs and implement

protocols for protection of children in war and conflict situation.

Non-Government Organizations

Report and participate in coordinated use of resources for care and rehabilitation of children and adolescents with MNS Disorders

Advocate for children in need of care and children with special needs

Adhere to national and local government regulations while implementing programs for children and adolescents.

Prioritize allocation of resources for CAMHS

Implement protocols for care, treatment and rehabilitation of children with MNS Disorders

Train or recruit personnel with appropriate skills to manage MNS Disorders

Sensitize communities on CAMH issues

Integrate CAMH programs to their programs and activities

Development Partners

Prioritize allocation of resources for CAMHS and child protection

Provide technical support to line Ministries in implementation of CAMH services

Support policy dialogue and advocacy for CAMHS and development at National and international level

Coordinate development partner support for CAMHS

Mobilize resources for CAMH services

Communities Create mechanisms and provide counseling and guidance services to children and adolescents in the community

Local Councils should identify and register child welfare and child abuse issues and supervise its members to ensure that they comply with remedial actions

Provide safety to children experiencing abuse and conflict

The local councils should disseminate laws to the community members

Community leaders and all community members should ensure that the environment is conducive for child growth and development

Ensure that children and adolescents with MNS problems are taken for care.

The community leaders will identify and record child abuse in the community and make reports on compliance with remedial action, leaders at sub counties will supervise village councils and make reports to police

Families Families should practice good parenting skills,

Promote communication among its members,

Keep conflict resolution channels open,

Support members to access MNS services in the health facilities

Protect its members from abuse and exploitation

Every stakeholder should plan, advocate, allocate resources, coordinate, monitor and evaluate all their activities.

7.0 Monitoring and Evaluation

An integrated multi-sectoral approach to M & E will be adopted. Every stakeholder has a duty to;

a. Develop annual work plans, integrate data collection tools into its system, b. Analyze, report and disseminate key data to stakeholders. c. All stakeholders should participate in coordinated monitoring and evaluation activities

and multi-sectoral evaluation meeting will be held annually to report on key indicators, both at District and at National level.

8.0 Service standards

Building skills

Ensure that the social skills that are particularly relevant for Mental Health and substance use are included in existing life skills programs.

Counseling

Improve the Mental Health and substance-related component in the training of people who counsel children and adolescents

Improve availability of mental and substance-related counseling services at key sites (e.g schools, health facilities, prison, streets)

Increase the availability of telephone hotlines in all official languages to address CAMH

Support self-help groups and families of children and adolescents with mental, neurological and substance use problems

Access to health services

Improve training of health personnel (especially nursing staff, social workers, counselors, psychologists, clinical officers, occupational therapists, medical officers, pediatricians, psychiatrists ) in the detection, diagnosis, and management of children and adolescents suffering from mental, neurological and substance use disorders, both in their specialized professional training and their continuing professional development.

Availability of dedicated clinics for children and adolescents and dedicated space for both clinics and inpatients?

Ensure that the management of children and adolescents with mental, neurological and substance-related problems is integrated into primary health care services.

Improve the consultation and liaison support in the field of mental, neurological and substance use services available to health workers at primary level.

Improve the capacity of the health services to offer detoxification and out-patient treatment services for substance abuse addiction

Increase the number of day and in-patient programs for children and adolescents with mental, neurological and substance-related problems.

Ensure that specialized health services for children and adolescents with the above characteristics are available in key sites such as prisons, health services and tertiary educational institutions.

Improve the detection rate for mental, neurological and alcohol and other drug abuse at antenatal clinics, and provide the appropriate services to reduce the incidence of fetal alcohol syndrome and related problems.

Identify and facilitate credible research projects to inform preventive initiatives Home/family/community

The home/family/community is the primary setting for the development of a safe and supportive environment as well as for building skills and providing information. Specifically, improving the relationships and communication between parents and other adults in the home would promote children and adolescent health and reduce risk behaviour. The home /family /community have not yet been prioritized as a site for children and adolescent health interventions. There is general lack of knowledge, guidance and support regarding effective parenting skills. There are insufficient links between the family on the one hand and educational and religious institutions on the other. Interventions at home should be aimed to:

I. Educate parents and other adults in the home regarding family health, including aspects that are specifically relevant for children with special needs;

II. Empower parents and communities in general to provide programs geared towards effective parenting;

III. Provide counseling services for parents and other adults in the home to improve relationship and communication.

IV. Selection and training of appropriate personnel to provide the educational and counseling programs, and to train others to do so.

V. Promoting and build capacity of caregivers such as family and community workers to provide effective home-based care for children and adolescents with chronic mental and physical health problems.

VI. Liaison with families, religious organizations, schools, and NGO’s to establish structures in the community to address parenting challenges.

VII. Motivation and encouragement of children and adolescents to form peer support groups

VIII. Facilitating linkages and communication between homes, schools and religious organizations;

IX. Improving mothers/caregiver-infant relationship, with special emphasis on the “Kangaroo Method”.

Schools

The school is an important site for the provision of interventions to address Mental Health since it has the potential to reach large numbers of children and adolescents in a cost-effective manner. The World Health Organisation (WHO) Mental Health Programme has provided a set of characteristics of what they refer to as “Child Friendly Schools”, which enhance the mental well-being of learners. The characteristics of child friendly schools include:

I. The promotion of tolerance and equality between boys and girls, between children and adolescents of different ethnic, religious and social groups.

II. The provision of a learning environment based on active involvement and co-operation in the teaching and learning processes.

III. An absence of physical punishment and of bullying; IV. The development of a supportive and nurturing environment; V. The fostering of connections between school and family;

VI. Valuing and supporting the development of young people’s creativity as well as their academic abilities, for example creating opportunities for recreation and creativity and use of natural talents.

VII. The promotion of self-esteem and self-confidence among the students. VIII. Assisting children who are failing academically to deal with their problems. Youth clubs/groups

Youth clubs/groups are an important location for congregating and for identity building. The majority of these clubs/groups is culturally oriented and may also serve as an ideal setting to identify peer group leaders who could be used in peer group training projects. Such groups may be involved and made to participate in various intervention strategies, for example, providing information through campaigns. There are several important factors that prevent the public health facilities from achieving their potential as sites of Mental Health service provision for children and adolescents:

Health services are relatively inaccessible, especially to the poor and those living in rural areas;

Few facilities cater for the Mental Health needs of children or adolescents; Many children and adolescents fear that their problems will not be kept confidential; There is limited numbero of trained professionals and expertise especially in rural areas,

to deal with child and adolescent Mental Health issues, especially at the primary level; and

There is often a poor relationship between youngsters (especially adolescents) and clinic personnel.

The following are strategies to increase the accessibility of health services to children and adolescents:

I. Increase the number of facilities such that they are accessible to a greater proportion of the population;

II. Make structural changes to the facilities to promote privacy and confidentiality; III. Allocate certain days or sessions for children and adolescents alone; IV. Have convenient opening hours, especially for adolescents and mothers with babies; V. Re-train and re-orientate health workers, with an emphasis on values clarification and

the development of interpersonal skills to promote good provider-recipient communication and respect for children and adolescents;

VI. Involve children and adolescents in the development of “adolescent friendly” clinics; VII. Develop a set of children and adolescents service standard to facilitate monitoring and

evaluation; VIII. Co-ordinate and liaise with NGO’s and community based organisations (CBOs) and the

private sector to strengthen and sustain child/adolescent friendly services; IX. Facilitate specialized training of child psychiatrists, medical officers, child psychiatric

nurses, psychiatric clinical officers, psychologists, occupational therapists, clinical officers and social workers.

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