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Review
State of the Nigerian child – neglect of child
and adolescent mental health: a review
O. Atilola
1,2
, O. O. Ayinde
3
, C. T. Emedoh
2
, O. Oladimeji
4
1
Department of Behavioural Medicine, Lagos State University College of Medicine Ikeja,
2
Federal Neuro-
Psychiatric Hospital Calabar,
3
Department of Psychiatry, University College Hospital Ibadan,
4
Department of
Epidemiology and Biostatistics, Faculty of Public Health, University of Ibadan, Nigeria
Background: As most child health initiatives in Nigeria lack a child and adolescent mental health (CAMH)
strategy, CAMH issues have remained obscure to the country’s policy-makers. The lack of current and
representative epidemiological data on the mental health of Nigerian children continues to be a barrier to
advocacy for CAMH policy initiatives. In view of the importance of CAMH to national development, there must
be a continued search for ways of bringing the state of CAMH in Nigeria to the attention of policy-makers.
Objectives: To use information from UNICEF’s State of the World’s Children as proxy data to speculate on
the state of child mental health in Nigeria.
Methods: With a view to discussing its CAMH implications, social and health indicators in the Nigerian child
were extracted from UNICEF’s 2012 edition.
Results: Most of the social and health indicators assessed reflect significant mental health risks. Up to 65%
of households live on less than US$1.25 per day, child malnutrition is evident in up to 40% of children, and
the primary and secondary school net enrolment ratios are only 63% and 25%, respectively. In addition, the
rate of attendance for antenatal care was 45%, and only 39% of deliveries were supervised by skilled birth
attendants. Child labour and under-age marriage is very common. A literature review demonstrates that
children living in these circumstances are at significant risk of mental health problems.
Conclusion: Current data on the state of Nigerian children contain indices that can serve as proxy
information for the state of CAMH in the country. Policy-makers need to invest more in pre-emptive child
health initiatives as a way of preserving the physical and mental health of children.
Keywords: Child mental health policy, Mental health risks, Children, Nigeria
Abbreviations
AIDS acquired immune deficiency syndrome;
CAMH child and adolescent mental health;
GER gross enrolment ratio;
HDI human development index,
HIV human immunodeficiency virus;
LAMI low and medium income;
MCHIP maternal and child health integrated pro-
gramme;
MICS multiple-indicator cluster surveys;
NAR net attendance ratio;
NCHP National Child Health Policy;
NDHS Nigeria’s Demographic and Health Survey;
NER net enrolment ratio;
SSA sub-Saharan Africa;
UNDP United Nation Development Programme
Introduction
With a population of about 160 million, 50% of whom
are children and adolescents, Nigeria accounts for up to
a quarter of the population of children and adolescents
in sub-Saharan Africa (SSA).
1
In the 2012 edition of the
United Nation Development Programme (UNDP), the
Human Development Index (HDI) score for Nigeria is
as low as 0.47 points.
2
This HDI score ranks the
country at 153 down the list of the 187 poorest
countries. Nigeria, as in all West African countries,
are in the low HDI African category.
2
Children growing
up in a setting of high child population and poor HDI
are expected to lack some resources for good nurturing,
especially in early life, and as such are at increased risk
of social, mental and physical health problems.
3,4
Inevitably, the focus of child healthcare in most low-
and medium-income (LAMI) countries had been on the
so-called childhood ‘killer’ diseases such as diarrhoea,
acute respiratory infections and malaria.
5
This focus
has almost excluded the social and mental aspects of
child health.
6
Scrutiny of the policy documents of recent child
health initiatives in Nigeria such as the Maternal and
Child Health Integrated Programme (MCHIP) and
the National Child Health Policy (NCHP) shows that
Correspondence to: O Atilola, Department of Behavioural Medicine, Lagos
State University College of Medicine Ikeja, Nigeria. Email: olayinka.atilo-
la@lasucom.edu.ng
ßW. S. Maney & Son Ltd 2014
DOI 10.1179/2046905514Y.0000000137 Paediatrics and International Child Health 2014 VOL. 000 NO. 000 1
they lack specific mention of child mental health. In
addition, the current national mental health policy
document did not reflect significant provision for
child and adolescent mental health (CAMH). The
magnitude of other child health issues such as HIV/
AIDS, malaria and maternal and child mortality has,
perhaps inevitably, continued to shape child health
initiatives.
6
Childhood mental health problems are common
worldwide
7
and are associated with significant morbid-
ity which affects families and society at large.
8,9
Meta-
analyses of surveys conducted in general population
samples in SSA yielded prevalence rates of childhood
mental health problems ranging between 13% and
20%.
10
The identified childhood psychopathologies
include, but are not limited to, hyperactivity, anxiety/
depressive and conduct disorders. Epidemiological
surveys in Nigeria have also demonstrated that child-
hood mental health problems are common.
11–13
Many
of these surveys, however, were undertaken several
years ago, and most lack the representativeness to be a
convincing CAMH policy advocacy tool.
The annual State of the World’s Children
14
pub-
lished by UNICEF is a potential source of representa-
tive data which, if carefully presented, interpreted and
contextualised, can serve as an advocacy tool.
Unfortunately such documents focus largely on child
and maternal mortality data and poor physical and
social indicators. Information on the mental health of
children is scarce. Unfortunately, local data on child
health such as in the most recent version of Nigeria’s
Demographic and Health Survey (NDHS)
15
also
focussed on providing data on the poor physical and
social health of children and adults alike, without once
mentioning mental health.
Inundated with such data annually, it is not
surprising that the focus of child health initiatives has
been on physical health, and that child mental health
issues have remained ‘invisible to policy makers’
6
in
LAMI regions, including Nigeria. Without the
resources to conduct a nationally representative epide-
miological survey of current childhood mental health
problems in Nigeria, there must be some way of
drawing the attention of policy makers to the relevance
of CAMH issues in child health initiatives. A possible
approach is to use the currently available data on the
state of children in Nigeria as a proxy for their mental
health risks. In the context of developing countries like
Nigeria, some studies have argued that identification of
potential risk factors for child mental health problems
canbeaneffectivewayofstimulatingCAMH
initiatives.
16
In this narrative review, the key indicators of child
health in Nigeria in UNICEF’s 2012 State of the
World’s Children
14
are examined with a view to
highlighting inherent mental health risks. It is hoped
that, by so doing, the mental health of Nigerian
children can be made more visible to policy-makers.
This paper is directly addressed to the Nigerian
government with regard to the policy implications of
its findings.
Methods
In writing this narrative review, the key indicators of
child and maternal health in Nigeria extracted from
UNICEF’s 2012 version of The State of the World’s
Children are examined.
14
UNICEF records the global
health of women and children by annual data
collection and analysis. This is undertaken by helping
countries collect data by multiple-indicator cluster
surveys (MICS). These data are the basis of the
statistical information often presented in UNICEF’s
annual State of the World’s Children report. The
data examine various aspects of the social circum-
stances and wellbeing of women and children which
include, but are not limited to, family financial
resources, child-health indicators, child-nutrition
indicators, child-education indicators and indicators
of the protection of women and children.
After examining and presenting the data, infer-
ences are drawn from the inherent child mental health
risks, even when such were not directly presented in
the UNICEF data. In drawing these inferences, we
relied on a selective review of local literature that
examined risk factors for CAMH. This method
accords with a recommendation that, when using
data as evidence for policy, analytical argument
contextualising primary or secondary data is valid.
17
Depending on how it is presented, interpreted and
contextualised, other MICS data generated by
UNICEF and other international non-government
agencies have been used extensively to influence
policies and programme interventions.
18–21
Results
UNICEF data on the basic social indicators of health
and nutrition and the education of children in Nigeria
are presented. Data on maternal health and wellbeing
and child protection in Nigeria are also presented.
Nigerian data are compared with the SSA average.
Basic social indicators
Of 32 million births in SSA in 2010, Nigeria
accounted for 6.3 million (y20%). Life expectancy
was 51 years compared with an SSA average of 54.
Other basic indicators are shown in Figure 1.
Health and nutrition
Of an estimated 3.1 million children ,15 years living
with HIV in 2010 in SSA, it is estimated that 360,000
(approximately 12%) of them live in Nigeria. In
addition, of the estimated 55 million children
orphaned in SSA, 12 million (approximately 22%)
Atilola et al. Child mental health in Nigeria
2Paediatrics and International Child Health 2014 VOL.000 NO. 000
live in Nigeria. Other indicators of health and
nutrition are illustrated in Figure 2.
Child education
Only an estimated 15% of Nigerian children were
enrolled in pre-primary education services in 2011
compared with 18% in SSA. Details of the educa-
tional statistics for children in Nigeria are given in
Figure 3.
Women wellbeing and child protection
In 2010, adult female literacy was 69% as a
percentage of that of men in Nigeria. This is slightly
lower than the SSA average of 76%. Also, in 2010, up
to 28 of every 1000 women aged between 20 and 24
had had their first birth before the age of 18 years.
Data on other aspects of women and child protection
are shown in Figure 4.
Discussion
The majority of child-related social and health
indicators for Nigeria assessed in this study are poor,
and often worse than the SSA average. More than
60% of Nigerians live below the poverty line of
US$1.25. Social inequalities are stark: only 15% of
total household income is available to the poorest
40%. There is a strong, long-established link between
poverty and poor mental wellbeing.
22
There are many
reasons for this. Parental poverty, for instance, can
impair the ability of parents to meet their children’s
social and emotional needs.
23
There is evidence also
Figure 1 Basic indicators of social circumstances of children in Nigeria (adapted from UNICEF, 2012).
18
The average for sub-
Saharan Africa is also shown for comparison. *Approximation, original figure for Nigeria was 3.7%.
Figure 2 Health and nutrition indicators for children in Nigeria (adapted from UNICEF, 2012).
18
The average for sub-Saharan
Africa (SSA) is also shown for comparison. The range of immunisation coverage for Nigeria is 66–79% (lowest for hepatitis B3
and highest for polio3) while the range for SSA is 61–85%.
Atilola et al. Child mental health in Nigeria
Paediatrics and International Child Health 2014 VOL. 000 NO.000 3
that high family income improves parental care and
thus benefits child mental health and wellbeing.
24,25
Furthermore, widespread family poverty and social
inequalities can increase the likelihood of children
being in situations which increase their mental health
risks. For instance, Nigerian studies have shown links
between family poverty and the risk of child neglect,
e.g. of becoming a street child, and of coming into
contact with child social-welfare systems.
26–28
There
are also reports from many parts of Nigeria that
parental poverty is the key element in children being
withdrawn from school, forced into marriage, enga-
ging in child labour, and living in various difficult
circumstances.
26,29,30
Poor families may not have the resources to
provide adequate nutrition for children. According
to UNICEF data, almost half of children under-5 in
Nigeria are under-nourished as measured by rates of
stunting of growth. The relationship between nutri-
tional deficiencies (macro- and/or micro-nutrients)
and poor mental wellbeing of children has been
modelled.
31
Suggested links include covariance
between nutritional deficiencies and other difficult
childhood circumstances. In addition, nutritional
deficiencies can interfere with the development of
secure attachments which can engender difficulties
such as a lack of sociability and self-discipline which, in
turn, can increase the risk of behavioural problems.
31
According to Bennet and Gunn,
32
‘‘nutritional inade-
quacy, in one form or another, is one of the largest
single non-genetic contributors to mental retardation
and aberrant neural development.’’
Child education is associated with an early sense of
self-esteem and confidence, as well as a range of
problem-solving skills which are critical resilience
factors in child mental health.
33
From a mental
health perspective, the benefits of education are
greatest when applied early.
34
Unfortunately,
Nigeria has a low (60%) primary school net enrol-
ment ratio (NER) against a background of a high
(90%) gross enrolment ratio (GER). The official UN
definition of GER (http://www.unesco.org/new/en/
education) is total enrolment within a country ‘‘in a
specific level of education, regardless of age,
expressed as a percentage of the population in the
official age group corresponding to this level of
education.’’ This is unlike the NER which is strictly
the share of children of official school age enrolled for
a specific level of education. A high GER with low
NER, as in Nigeria, suggests that a large proportion
of children in the country commence formal basic
education later than the national official age. This
Figure 3 Educational indicators for children in Nigeria (UNICEF, 2012).
18
The average for SSA is also shown for comparison.
GER, gross enrolment ratio; NER, net enrolment ratio; NAR, net attendance ratio. *Primary school.
Atilola et al. Child mental health in Nigeria
4Paediatrics and International Child Health 2014 VOL.000 NO. 000
will erode some of the mental health benefits of early
education.
Furthermore, being in school can protect children
from situations that can adversely affect their mental
health. In the context of SSA, being out of school has
been linked to engagement in some of the worse
forms of child labour,
35,36
being forced into child
marriage or becoming pregnant as a child,
37–39
involvement in armed conflict,
40,41
and becoming a
delinquent or street urchin.
26,27,42
Again, with a
secondary school net attendance ratio in Nigeria of
about 44%, a large proportion of adolescents are not
at school.
As regards child physical health in Nigeria,
immunisation coverage is 66–79% (average y70%)
and the gap has been attributed to social and cultural
barriers which limit acceptance, and difficulties of
vaccine distribution.
43,44
This increases the risk of
vaccine-preventable diseases in children such as
poliomyelitis, measles and pertusis. Some vaccine-
preventable diseases can lead to chronic neurological
(e.g. poliomyelitis) or neuropsychiatric (e.g. measles)
sequelae. Widespread neuropsychiatric sequelae in
unvaccinated children after a measles outbreak was
recently reported from South Africa.
45
Some vaccine-
preventable diseases can cause mental health pro-
blems in later childhood, either from chronic physical
morbidity or acute or chronic effects on the brain.
According to UNICEF data, maternal literacy and
use of child-health resources are also poor in Nigeria.
For instance, adult female literacy rate as a percentage
of men’s is as low as 69%.
14
In other low-resource
settings, maternal education/literacy has been found to
be a resilience factor in terms of children’s mental
health, independent of exposure to poverty and other
social adversities.
46
Maternal literacy can also improve
the social and economic capacity for childcare in
general.
47,48
In a recent Nigerian study using nation-
ally representative data, maternal education was the
‘‘only individual-level variable that is consistently a
significant predictor of (maternal and child-health)
service utilization.’’
49
Poor use of some maternal and
child-care resources can endanger the mental health
and wellbeing of children. The percentage of women
who attend antenatal care in Nigeria is as low as 45%
while only 39% of deliveries are supervised by skilled
birth attendants.
14
Poor use of maternal health
services is an established risk factor for poor obstetric
outcome.
50,51
Studies in Nigeria have implicated poor
obstetric outcome as a key risk factor for poor social
and mental health in children.
52,53
As regards child protection, up to 17% of children
below 15 years of age are already ‘married’ in Nigeria.
Setting aside the legality and cultural underpinnings of
such marriage contracts, child marriage can affect
educational attainment and interfere with the sociali-
sation of children.
54
In addition, child marriage
increases the risk of exposure to domestic violence
and marital abandonment.
51,54
All these factors can
increase the mental health risks to which these young
people and their children are exposed.
It has been estimated that up to 30% of Nigerian
children are involved in child labour; this often
involves a degree of coercion and exploitation,
Figure 4 Key indicators for women and child protection in Nigeria (UNICEF, 2012).
18
The average for SSA is also shown for
comparison.
Atilola et al. Child mental health in Nigeria
Paediatrics and International Child Health 2014 VOL. 000 NO.000 5
resulting in adverse psychological impacts.
55
Child
labour can also affect mental health by interrupting
schooling and cognitive development, and is often
associated with physical and emotional abuse.
55,56
Up to 360,000 children (aged 0–14 years) in
Nigeria are infected by HIV, which represents about
9.1% of the estimated 3.3 million children and adults
living with the virus in the country.
14
About
1.7 million Nigerian women of reproductive age are
estimated to live with the virus;
14
approximately 4.5%
of women attending antenatal clinics are sero-
positive, and up to 7.7% in some regions.
57,58
Children living with HIV in a country such as
Nigeria face many social and psychological difficul-
ties, including prejudice. Studies in various parts of
the world including SSA have found a high level of
psychiatric morbidity in children and adolescents
living with HIV and in those orphaned by the
disease.
59–62
Finally, about 50% of Nigerians live in urban
areas, with an urban growth rate of 3.7% per annum.
As stated above, high rates of poverty combined with
a highly urban population can lead to large inner-city
slums.
63,64
Nigeria has many such slums which lack
basic social amenities
63
and are fraught with many
problems such as delinquency, prostitution, gang
activity and drug peddling.
63
Children being raised in
such settings have been found to be at greater risk of
mental health problems than their counterparts in
other areas of the country.
65,66
Implications for child and adolescent mental
health services and policy in Nigeria
Poor social indicators for children affect mental and
physical health equally. It is also apparent that the
key factors in mortality and poor physical health (the
current priority of child health policy-makers in
Nigeria) are also risk factors for poor mental health.
Perhaps part of the reason why CAMH is not
receiving the attention it deserves is because only
physical health is considered in national child well-
being surveys (e.g. the Nigeria Demographic and
Health Survey
15
). CAMH is scarcely mentioned. The
present discourse aims to provide a template to
ensure that such surveys also consider CAMH issues,
thus rendering them less ‘‘obscure to policy makers’’
6
in Nigeria.
The mental health risk inherent in physical health
risks is a good reason why policy-makers in Nigeria
should incorporate CAMH initiatives into the
country’s overall child health programme. The
Maternal and Child Health Integrated Program
(MCHIP)
67
for Nigerian children under 5 years of
age lacks specific guidance for CAMH. Common
child neuro-psychiatric disorders such as intellectual
disabilities, hyperkinetic disorders, autistic spectrum
disorders, and attachment and conduct disorders can
be detected in the first 5 years of life and can remain
stable into late childhood.
68,69
Simple screening tests
such as the Child Behaviour Checklist,
70
Strength and
Difficulty Questionnaire,
71
Modified Checklist for
Autism in Toddlers
72
can detect childhood neuropsy-
chiatric disorders in those as young as 3–5 years and
can be administered by non-specialists in primary
maternal and child clinics. Such screening would
enable early detection and treatment of common
mental disorders in children attending for routine care
such as immunisation and for curative medical
attention. It is even more important to incorporate
CAMH services into the health care of older children
and adolescents since most psychiatric disorders first
occur at these later ages.
73
Further research into the
design of a comprehensive integrated child mental
health service in Nigeria is needed.
There is a great shortage of CAMH practitioners in
Nigeria
74
and ways need to be found to bridge the
human resource gap which will follow the scaling-up
of child mental health services. Robertson et al.
74
argued that the few general psychiatrists in SSA
should have complementary training in child psy-
chiatry to bridge such gaps. In Nigeria, recent views
on how to bridge gaps in CAMH service provision
includes structured bilateral liaison between psychia-
trists and paediatricians in providing such services.
75
Improving the capacity of other stakeholders in child
health (teachers, school counsellors, primary health
physicians, social workers) to provide basic CAMH
services has also been advocated.
76,77
Improved access to curative CAMH services is
important in a resource-constrained country such as
Nigeria in which many children may already have
serious and debilitating mental illnesses. Improved
access to child mental health services is however not
sufficient: it should be complemented by pre-emptive
and preventive strategies. Child and adolescent mental
health policies in a country such as Nigeria must strike
a balance between curative and preventive strategies.
Striking this balance requires in-depth understanding
of the care environment of children, and it is important
to invest more in aspects of care which are likely to
have most impact.
78
These aspects include early
childhood care initiatives (maternal care, immunisa-
tion, nutritional support and early-education); child-
sensitive social protection schemes, promulgation and
enforcement of child protection legislation, support
for the most vulnerable families, and the redistribution
of wealth. These strategies should be complemented by
efforts to underpin other areas of child care such as
restorative CAMH services.
78
It is critical to these recommendations that the
government of Nigeria increase funding of all
programmes for child health and survival, including
education, particularly of females, and other early
Atilola et al. Child mental health in Nigeria
6Paediatrics and International Child Health 2014 VOL.000 NO. 000
childhood care initiatives. Some of the additional
funds can then be channeled towards specific CAMH
strategies mentioned in this paper rather than re-
allocating child health-care funding. Relevant national
data are scarce but will be needed if CAMH initiatives
are to be incorporated into general child health-care.
The Nigerian government and international donor
agencies need to support efforts to generate such data.
Such data should include prevalence studies of
common childhood neuro-psychiatry disorders, deter-
mination of socio-demographic correlates of child
mental health problems, evaluation of unmet child
mental health service needs, and the examination of
barriers to accessing child mental health services by
vulnerable children.
The UNICEF data used as the main source of
information for this paper may be the best available, but
they have some limitations. Firstly, they are often based
on information supplied by member country govern-
ments – usually by the countries’ Office of Statistics or
similar bodies. Given the limited number and scope of
epidemiological data on childhood physical and mental
health in Nigeria, it is unlikely that much of the
UNICEF data on Nigeria would have come from direct
epidemiological research. It is therefore likely to have
come from a combination of government supplied data
and modeling/extrapolation from the limited data
available. This allows both under- and over-estimation.
Secondly, the UNICEF data used in the present
discourse did not take into account of regional
differences. Regionally stratified data from the
Nigerian Demographic and Health Data (NDHD)
79
show wide variations. The primary-school NER in the
NDHD, for instance, was higher in urban areas than in
rural ones (74% vs 55%). Also, there were wide regional
difference in the NER; for example, the figure was 42%
in the north-west and 83% in the south-west. Therefore
the validity of some of our assertions may vary between
regions of this vast and diverse country. However,
important as they are, these limitations are unlikely to
diminish significantly the import of the current discourse.
In conclusion, currently available data on the state
of Nigerian children contain indices that can serve as
a proxy for their possible mental health. The paper
advocates a comprehensive policy for the incorpora-
tion of CAMH services into all child health initiatives
in Nigeria. It also advocates greater investment in
pre-emptive child health initiatives to protect the
mental health and wellbeing of children. These
recommendations apply to most countries in sub-
Saharan Africa which are in a state of development
similar to that in Nigeria.
Disclaimer statements
Contributors: OA conceptualized the paper, organized
the resources needed, developed the manuscript, and
approved the final version. OOA, CTE, and OO all
made useful suggestions in the conceptualization of
the paper, assisted in securing some specific resources,
read and approved the final versions of the paper.
Funding: This is a self-funded research.
Conflicts of interest: None.
Ethics approval: None.
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