CHILD AND ADOLESCENT MENTAL HEALTH IN LMIC: APPLICATION OF TASK-SHARING APPROACHES AND AN EXAMINATION OF INTERGENERATIONAL TRANSMISSION OF RISK

Abstract

Children and adolescents in low- and middle-income countries (LMIC) suffer heightened vulnerability for the development of mental health conditions which is exacerbated due to enduring socioemotional, economic, and biological risk factors. The constellation of co-occurring adverse childhood experiences (ACEs; e.g. poverty, maltreatment, household dysfunction, exposure to violence) confer heightened vulnerability for the development of mental health disorders that may persist into adulthood. Although the mechanisms for transmission from one generation to the next has not yet been fully elucidated, contemporary evidence has converged primarily on maternal mental health as a key mediator between childhood exposure to ACEs, and the subsequent mental health of her children. Access to mental health assessment or treatment resources in Kenya are limited or non-existent. Due to the heightened risk for intergenerational transmission of mental health problems across generations, with support from the World Health Organization and key stakeholders in Kenya, the development of task-sharing approaches to address the unmet psychological needs of children and mothers has been advocated for. Task-sharing involves the rational redistribution of mental health care tasks from higher cadres of mental health professionals to non-specialized community health care workers in order to increase the capacity for, and access to, mental health services across Kenya. This dissertation seeks to explore: 1) the development of a partnership between the Africa Mental Health Research and Training Foundation and McMaster University to explore the use of task-sharing in the development of a technology-supported assessment for common mental disorders in children and adolescents; 2) the validity and reliability of the newly developed International Mobile Assessment for Children and Teens (IMPACT) administered by non-specialized community health workers when compared to a gold-standard assessment, the MINI-KID, when administered by trained psychology graduate students, and finally; 3) the association between maternal exposure ACEs and the subsequent mental health of her children, mediated by maternal mental health. The first study outlines the process of the development of the IMPACT using a novel blending of emic-etic approaches, and the practical evaluation of the IMPACT by ten local community health workers. Results from this study demonstrated the demand for, and utility of, the IMPACT and outlined the practical considerations of conducting field work of this nature. The second study examined the diagnostic agreement (e.g. validity) of mental health conditions in Kenyan school children (n=189) between the IMPACT and the MINI-KID. The results of this study demonstrated relatively high agreement between the diagnosis of common mental disorders in children between the IMPACT and the MINI-KID. The third study explores the relationship between ACEs (Y-VACS) of mothers (n=149) and the socioemotional wellbeing of her children (e.g. internalizing and externalizing problems; CBCL), mediated by maternal mental health (CBCL). The results of this study demonstrate the association between maternal ACEs and child internalizing and externalizing behaviours, mediated by maternal mental health and moderated by maternal education. Collectively, the results of these dissertation studies support the use of task-sharing approaches for the assessment of common mental disorders in children and adolescents, by non-specialized community health workers and that the transmission of mental health problems between generations is associated with a multitude of complex and inter-related factors (e.g. maternal ACEs and maternal mental health), exacerbated by chronic and co-occurring adversity. Additionally, the results of these studies demonstrated the need for further research that prioritizes the equitable accessibility interventions that target the mental health related-sequelae experienced by maternal-child dyads exposed to chronic and enduring adversity in LMIC.