Over kinderen, hun psychische problemen, hun ouders en hun behandelaars.

A day in the life of a visiting child-psychiatrist in Addis Ababa – part 2

Henrikje Klasen took six months leave from her job as Head of Training in Child Psychiatry in The Hague, Netherlands, to move to Ethiopia with her family. There she supports the Psychiatry Department of the University of Addis Ababa in the development of their child mental health services. This week, she tells about some of her experiences in three posts on De Kennis – Blogs.

HK 01Next, we start seeing patients. There are two new patients and a number of follow-ups scheduled for each doctor in the morning session. Patients come in early and just wait to be seen in order of arrival. The rooms and waiting areas are not particularly child friendly. There are almost no toys, no play-areas or pictures, not even color pens and paper. The doctor wears a white coat and sits behind the desk. I sit in to supervise the trainee and sit next to him. Fortunately all patient notes are written in English and, as the trainees are used to foreign supervisors, they pause after each section of the interview to fill me in on the history. A few patients this morning are particularly memorable.

First, we see an 8-year-old boy. After short introductions, his mother sends him out of the room and tells us that when the boy was in kindergarten (age 5/6) she left him alone for a few hours. When she came back he seemed disturbed. Later on she found lacerations round his anal area. The boy had always denied that anything had happened to him, but ever since the incident he had become hyper alert, scanning the rooms he is in. His school performance dropped, he could no longer concentrate and developed behavioral problems. He had been seen in the clinic for a couple of years (each time by a different resident) and had been tried on imipramine, amitriptyline and risperidone. He had developed memory problems and a tremor as side effects of the medication. Everyone who saw him asked him about the incident but he had not confided in anyone. The current resident tries the same strategy with the same result. I suggest that the new clinical psychologist could see the boy individually for a number of sessions to build up his trust, but the resident feels skeptical. I might need to discuss this with the consultant at a later stage. For now we are at least reducing the boy’s medication, give some parenting advice for the behavioral problems and a follow-up appointment. This is the third boy with suspected sexual abuse I have seen in this clinic in just two weeks.

Then an 11-year-old boy, Fekadu (all identifying information has been changed), comes in with an adult male, who turns out to be a relative of the boy from Addis; the boy lives about 300km away, in the country. The boy is quite dirty and poorly dressed in clothes that are far too small. He is a terrible sight, jerking and twisting the whole time, hardly able to utter a word or to stay in his seat. I suspect cerebral palsy but the movements do not look quite typical. I see the resident listening to Fekadu’s heart: “Now why might he do this?”… something stirs deep in my memory… Finally the resident tells me that the boy had been quite normal until the age of 7; even though the relative did not know of any infectious disease at the start of the movement disorder, he suspects Sydenham’s Chorea, particularly as he could hear a heart murmur. This time it is my turn to say “wow, I have never seen this before”. Again the iPad comes in handy and I google that Sydenham’s Chorea was one of the most common psychiatric presentations in Europe before the wide use of antibiotics. While easily treated at the time of the infection, now, 4 years later, the usefulness of antibiotics is questionable and treatment is mainly symptomatic, with haloperidol and valproate most commonly used. We test for streptococcal antibodies to see whether they can still be found and just hope that in Fekadu’s case the illness might still be self-limiting, as it often is. We also make a referral to cardiology and hope the relative will take him there before his return to the countryside.

The next patient is very typical for our clinic, where about 50% of children present with some form of learning disability, sometimes in the context of epilepsy, infectious disease or with autistic features (or, of course, in combination). A 7-year-old boy, Yohannis, from outside Addis comes with a severely autistic picture and developmental delay. He makes no eye contact, hardly speaks, does not seem to recognize people, does not respond to his name being called, holds his hands over his ears and behaves in a hyperactive way. He sleeps badly and can be physically aggressive. No school will take him as there is no special needs education provision outside the capital. He is just too disruptive to attend normal school, where class sizes of 80-90 children are quite frequent. He comes for a repeat prescription of risperidone, which has made life more tolerable at home. The remarkable thing, which I hear frequently, is that according to parents his development was quite normal until he was about 4 years old (including talking, playing with others and interacting). I am not sure, whether he has some sort of acquired problem (maybe due to an infection or epilepsy), which presents with an autistic picture, or whether parents just did not recognize early signs of autism as they are not alert to them.

The following patient is Dawit, another profoundly disabled 8-year- old. In contrast to the previous patient he makes good eye-contact but shows little adaptive functioning and communication. He runs through the room, picks up items, plays for a while with toys offered and tries to grab items from the examiners in quite an angry, oppositional way. The story is a sad one. Apparently he lost all his skills in only 4 months. In first grade he was the top student in his class—of 80-90 pupils. By the end of year 2 he was number 3. Since the summer holidays he is supposed to be in 3rd grade,
but 4 months ago, at the 
beginning of the new school
year, he started having 
seizures and slowly started 
losing his previously acquired
 skills. Parents took him to the 
local health center (which 
has no child mental health
 provision) as well as to the
“holy water”; neither helped.
The family is not from Addis,
 so it took a while to organize a 
trip to the capital to have him 
assessed here. We conduct 
some blood tests today to
 exclude an ongoing infection 
and start anti-epileptic
 medication even before an 
EEG can be arranged (there
is a 1-3 months waiting list).
We hope to arrest the decline
 but there is little hope Dawit will recover the functions already lost. A boy, who might have well been one of the top contributors to his community will now spend his life needing care from others; very sad. When I ask psychiatry trainees why so few of them are interested in CAMH they tell me about children like Dawit, who make them feel hopeless and sad. They see child psychiatry as a discipline predominantly dealing with learning disabilities and mental retardation.

The last patient of the morning is Michael, a bouncy 7 year old, who looks at me with bright, curious eyes. He runs around the room, almost climbs out of the window, touches everything and won’t sit still for a moment. Only when I show him my box of toys can I capture his attention for a while. He interacts well, shows reciprocity and compliance in the play, learns little patters in the game and even repeats some English words. After a few minutes, however, he is off again, almost knocking the (broken) computer off the table and exploring some books on the shelves. At last his mother gives him her phone and he starts a computer game, which finally calms him down. The story is surprisingly typical of children with ADHD: he did all right in kindergarten, where he was allowed to play and move around the class. As soon as first grade started and he was expected to sit still, things went wrong. He was first punished and eventually dismissed from school. At the age of 7, he has already been expelled from three schools and there seems no hope that another school will take him. And so, this bright little guy might never get the education he deserves. Methylphenidate is not available in Ethiopia, although some ask relatives to send it from abroad at high cost to the family. Psychosocial interventions, like sitting children with ADHD in the front of the class, giving them extra attention and short tasks are impossible given the huge class sizes. Teachers are not prepared to disrupt everyone’s learning for the sake of one child. Eventually we prescribe imipramine, an evidence-based third line medication for ADHD with more side effects and a smaller effect size than methylphenidate. It seems the best option given the circumstances. We also write a note for school, hoping he will find one that will have him.

It is about 12:30 by the time we finish the clinic. All in all it was an average caseload for a morning. Doctors tend to work in 2-3 rooms, each seeing 5-8 patients in a morning. Repeat prescriptions are often done by the “health officers” (a profession in between nurse and general practitioner). In the afternoons patients can be seen for psychotherapy, but that rarely seems to happen. Given that this is the only dedicated child mental health service in the country, it is actually surprising that it is not busier. It seems many patients, parents and referrers are just not quite sure about the existence of this service and about the benefits it could offer.

This article was also published in IACAPAP Bulletin 40 (February 2015).

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