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- Materials and methods
Nigeria is currently in a very difficult situation in terms of optimal childcare. This is not unconnected with the fact that current social indicators in the country are unlikely to be able to support optimal provision of the ingredients for physical, social and mental well-being of children. With a burgeoning 75 million children to cater for (Central Intelligence Agency 2011), widespread poverty and social inequalities in the country (Earth trends 2003, Omotola 2008) has denied many families the cohesion, stability and resources needed for proper childcare (Ebigbo 2003). Countries with adverse socio-economic indicators, as currently obtainable in Nigeria, are known to have a high proportion of dysfunctional families; an increased risk of situations of child abuse and neglect, and need for large number of children to access social welfare services (United Nations 2003). This situation has also been linked to a higher risk of juvenile delinquency and as a consequence, children and adolescents coming in contact with the juvenile justice system (Oloruntimehin 1970, Odejide & Toye 1976, Ozen et al. 2005).
There is documented evidence that a large and increasing number of children and adolescents in Nigeria have had or are at risk of having contact with the social welfare or juvenile justice systems. Figures from the official data of the Nigerian Prison Services in the year 2011 showed that in the preceding 5 years, there was a steady, almost geometric rise in the number of children and adolescents processed through the criminal section of the juvenile justice system (Ogundipe 2011). There are also reports that the streets of Nigeria are being inundated daily with hordes of different categories of neglected children and adolescents in need of social welfare services (Abdulmalik et al. 2009, Aransiola et al. 2009), many of whom end up in the social welfare or juvenile justice institutions.
Another expected repercussion of the adverse social indicators in Nigeria is poor early childhood care, especially ante and perinatal childcare. Recent reports showed that up to 12% of pregnant women in Nigeria were malnourished and that only 58% and 35% of a nationally representative sample of pregnant women in Nigeria had access to antenatal care and attendance of a skilled birth attendant respectively (National Population Commission and ICF Macro 2008). Reports like this are probably the most worrisome aspect of the socio-economic situation in Nigeria from child health perspectives. This is because many of the childhood mental and neurological disorders take their root from the quality of transition from ante-partum to postpartum life. In a study of a cohort of children and adolescents referred to a Child and Adolescent Mental Health (CAMH) clinic in Nigeria for sundry neurological and mental health problems, about a third had a history of obstetrics complications, the commonest of which was perinatal asphyxia (Omigbodun & Bella 2004). Perinatal asphyxia is the leading adverse birth outcome in the settings of poor maternal care (Costello 1994) and Nigeria currently has one of the highest rates in sub-Saharan Africa (UNICEF 2009).
Perinatal asphyxia has been reported to be associated with a wide range of chronic disabling neurological disorders ranging from cerebral palsy (Odding et al. 2006) through cognitive deficits (Frank-Briggs & Alikor 2011) to epilepsy (Ogunlesi et al. 2008). Epilepsy, neurological deficits and cognitive deficits either independently or in combination, are risk factors for being abused or neglected among children in different parts of the world (Sullivan & Knutson 2000, Spencer et al. 2005). The increased risk has been linked with the higher caregiver burden associated with such chronic disabling conditions (Maes et al. 2003). Other than delinquency and crime, child abuse and neglect is also a major reason for placing children and adolescents in institutional care in Nigeria.
Nigeria runs a ‘multipurpose’ juvenile justice system in which both child offenders and child victims are processed through the juvenile courts. These are then committed to a borstal or remand facility. Borstal institutions in Nigeria are mainly for young offenders while remand homes are like refuge centres for maltreated and abandoned children. This divisions are not however strict as a few offenders can be diverted to the remand system if the borstal systems get overwhelmed. Children in institutional care are living in a difficult circumstance and as such are expected to have higher social and health needs. The few health needs assessment studies conducted among adolescents in custodial care in Nigeria had focused on psychopathology and social needs (Ononye & Morakinyo 1994, Ajiboye et al. 2009, Bella et al. 2010). At least one of these studies had hinted that neurological and intellectual disabilities may also be an issue among these children (Bella et al. 2010). Children with neurological disorders and intellectual disabilities have been found to constitute a bigger management burden in custodial care (Smith et al. 1990) and place a higher demand on the often limited resources. Available neurological and mental health services in the best of climes hardly cover more than a small fraction of children and adolescents in need of such services (Burns et al. 2004).
Therefore, in a country like Nigeria where paediatric neurology, CAMH and special education services are limited; provision of such services for children in custodial care will require careful planning. This will include a well-designed assessment to determine the needs for neurological, neuro-physiotherapy, psychiatric and special education services to children in social welfare and juvenile justice institutions. Such services have a potential to improve quality of life and the success of social re-integration of these children and adolescents. As part of a multidisciplinary mental health outreach programme to a remand home in South-West Nigeria, the prevalence and spectrum of neurological and intellectual disabilities among adolescents in the facility was examined in a cross-sectional comparative study design.
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- Materials and methods
Epilepsy, neurological deficits and intellectual disabilities were significantly higher among the child-neglect group compared with both the comparison group and the adolescents on ‘criminal code’. This is in line with earlier research findings, which show that chronic disabling conditions increase the chances of being maltreated or neglected as a child (Sobsey 1992, Sullivan & Knutson 2000, Spencer et al. 2005). Sullivan & Knutson (2000) reported that children with any type of disabling condition were more likely to be maltreated or neglected compared with children without disabilities. Sobsey (1992) also reported that children with intellectual disabilities were 4–10 times more likely to be victims of maltreatment and neglect than those without intellectual disabilities. The higher risk of neglect and maltreatment among children with chronic disabling conditions may not be unconnected with their higher dependence and needs for care. The social and economic disadvantage that may increase the risk of having children with disabilities in resource constrained countries like Nigeria in the first place may also increase the stress of parenting. Therefore, the burden of caregiving for children with disabling conditions is likely to be higher when coupled with other social challenges like poverty.
Aside this, one specific factor that can increase the burden of caring for and the risk of maltreatment or neglect of children with chronic neurological disorders in Nigeria include widespread wrong notions about the causation and outcomes of these conditions. Several studies in Nigeria and indeed, other West African countries have documented that a large number of mothers and school teachers attributed the cause of childhood epilepsy, neurological deficits and intellectual disability in children to possession by evil spirits, witchcraft or virulent contagion (Alikor & Essien 2005, Birbeck et al. 2006, Ofovwe & Ofovwe 2007, Frank-Briggs & Alikor 2011). Citing the ‘demonic’ or ‘contagion’ theory of causation of different types of chronic disabling neurological conditions as a rationale, 48% of a sample of teachers in a Nigerian community was of the opinion that children with epilepsy should be withdrawn from school (Alikor & Essien 2005). In another study, about 30% of mothers of children attending a neurological clinic in Nigeria reported that they maintain minimal social contact with their children with epilepsy, and were of the view that affected children would not achieve much in life (Frank-Briggs & Alikor 2011). Similarly, majority of mothers of children with chronic neurological deficits in some Nigerian communities were ashamed and embarrassed to be seen with their affected children in public (Ofovwe & Ofovwe 2007) and thought them as bearers of misfortune and evil powers (Ofovwe & Ofovwe 2007).
These widespread beliefs can engender social distance from and neglect of affected children and adolescents. Attempts at exorcizing such children from perceived evil-spirit possession may also lead to various forms of maltreatment. Physical punishments and maltreatment may also be used as a retribution for the perceived possession of evil powers. The perceived ‘evil’, ‘extra-terrestrial’ or ‘infectious’ nature of these neurological conditions may also lead to stigmatization and discrimination of both the child and their mothers. A lack of adequate social support for parents and lack of educational facilities for the care of children with chronic disabling neurological and intellectual disabilities in resource-poor countries like Nigeria can also add to the burden of care. Confronted with a combination of stigma and misconceptions, high caregiver burden and a lack of social support; caregivers of children with chronic disabling neurological conditions may get frustrated and consider abandoning or neglecting their affected children. Doing away with children by way of abandonment has been cited as a well-considered form of respite from the burden of care, shame and fears associated with caring for children with disabling conditions in Nigeria (Abasiubong et al. 2008). The foregoing may explain the much higher prevalence of neurological deficits and epilepsy among the adolescents admitted into the remand home haven being maltreated or abandoned.
Impaired intellectual functioning was found in almost half of the remand home participants in this study. Although the SIT is not designed to assess for deficiencies in adaptive functioning, the fact that the adolescents in this study who had scores that fell within the range of ‘intellectual disability’ also had significantly lower CGAS scores suggest some reliability of the SIT in detecting such. The mean CGAS scores of 48 for the remand home participants who had intellectual disabilities fell short of the normative score of 81, which corresponds with ‘good functioning’. This observation suggests actual impairments in the functioning of the remand home participants that were adjudged to have intellectual disabilities using the SIT IQ scores. The 22.4% prevalence of intellectual disability among the children and adolescents within the juvenile facility in this study is higher than the weighted average of 12.7% found in the results of a meta-analysis from developed countries (Casey & Keilhtz 1999). This is most likely due to the fact that the participants in this study were not exactly the typical ‘juvenile justice sample’. The majority were actually remanded in the Home for maltreatment and abandonment rather than juvenile crime or delinquency. Although lower levels of intellectual functioning have been found among incarcerated young offenders (Perske 1991), particularly high prevalence of intellectual disabilities has been found among abandoned, maltreated or children in other situations that may warrant protective custody (Sullivan & Knutson 2000, Spencer et al. 2005). It does appear from current study that social welfare institutions in this region may be fast becoming a dumping ground for children with unrecognized or unattended neurological or intellectual disabilities.
Being a cross-sectional study, this study cannot establish whether the lower intellectual abilities of the participants in the remand home were confounded by their stay in the Home. However, the finding of high prevalence of low intellectual functioning among the adolescents in the Home still raises serious concerns. This is because regular educational services in the facility where the present study was conducted, and in similar facilities across the country, are either skeletal or non-existent. The same goes for resources for special education. Although not usually classified as intellectual disability per se, the finding in this study that adolescents with borderline intellectual functioning also had significantly lower CGAS scores is a cause for much concern. Earlier research has shown that children with borderline intellectual functioning also suffer some degree of social and academic impairment (Karande et al. 2008).
The needed social and intellectual skills to help prepare for life after and outside the remand home will be lacking and the chances of successful reintegration into the community will be slim, if the educational needs (regular or special) of these children and adolescents are not addressed. Article 2 (1) of the United Nations Convention on the Rights of the Child (CRC) (United Nations 1989) guarantees that rights, including right to education, of any child should not be denied by reason of status or disability. Article 28 of same convention provides that all children should be given education on equal opportunity basis. Children and adolescents with intellectual disability within the juvenile justice and social welfare systems constitute a very vulnerable group whose needs can only be met with purposive efforts.
Young persons with intellectual disabilities will often require specialist interventions from appropriately skilled professionals. Therefore, educational services for young persons with intellectual disability within the juvenile justice and social welfare systems should be part of any national or regional CAMH service. This can best be provided in juvenile justice and social welfare settings, where co-morbid psychiatric disorders are usually very common (Teplin et al. 2002, Abram et al. 2004); by a well-coordinated multidisciplinary team (Chapman et al. 2006). Such teams should consist of child and adolescent psychiatrists, learning disability experts, psychologists, social workers, paediatricians, physiotherapists and experts in juvenile justice jurisprudence.
In the same vein, article 24 (d) of the CRC requires that state parties commit themselves to pre- and postnatal care at the primary care level as a means of reducing child morbidity and mortality and by extension the incidence of childhood disabilities. The absence of ancillary information on the course and onset of the neurological deficits found among the adolescents in this study made a definitive conclusion on the diagnosis difficult. However, the pattern of almost all the neurological deficits found were in keeping with the pattern earlier reported among children with neurological sequelae of perinatal asphyxia in Nigeria (Ogunlesi et al. 2008, Frank-Briggs & Alikor 2011). Studies from Nigeria have described slurred speech, hypertonia, hyper-reflexia, muscle atrophy, dyskinesia and epilepsy as among the most frequent neurological sequelae of perinatal asphyxia in this region (Ogunlesi et al. 2008, Frank-Briggs & Alikor 2011). If indeed the neurological deficits found among the abandoned or maltreated adolescents in this study arose from perinatal asphyxia as we strongly suspect, this study then provides another rationale for an urgent need to scale up availability and quality of child and maternal care in Nigeria as one way of ensuring child-right protection and reducing the rising cases of child neglect in the country.
Furthermore, study also makes a further case for a need for public enlightenment on the gains of accessing quality obstetric and neonatal care where possible. Enlightenment campaigns should also endeavour to dispel misperceptions about neurological disorders. Government and donor agencies must as a matter of urgency provide facilities for respite care, counselling and support for mothers of children with chronic neurological disorders. Such facilities can also serve as a community-based source of referral to, as well as a collaboration point with, other relevant service providers like paediatric neurologists, child psychiatrists, special education experts and paediatric physiotherapists. Such centres may also serve as a community-based meeting-point for group therapy among mothers of children with disabilities. In view of the popularity of the faith-based organizations among community dwellers in Nigeria, worship centres can also serve as a setting for public enlightenment in this case. These measures will reduce the burden of care and the feeling of despair among mothers of children with neurological disorders and can ultimately reduce the risk of abuse and neglect of such children.
Above all, a longer-term solution to adverse child outcome in Nigeria is a sincere and concerted effort to maximize the use of the nation's vast human and material resource. Official corruption must be tackled through a culture of transparency and accountability in governance. Child poverty must also be reduced through social protection schemes. Affordable, accessible and qualitative maternal and child preventive and restorative healthcare must be made available through re-awakening of the primary care driven system of healthcare.
This study was part of an initial needs assessment conducted by the ongoing multidisciplinary Mental Health Outreach Programme to the IJRH, a local model for service provision for children and adolescents in juvenile justice or social welfare custodian care. The ongoing multidisciplinary collaboration programme was designed for the provision of neuro-psychiatric, social, educational and legal services for children and adolescents within the ibadan juvenile remand home. The MacArthur-Foundation sponsored collaboration includes the Child and Adolescent Psychiatry unit, the Paediatric Neurology Unit, the Institute of Child Health, the Paediatric Dermatology unit, the Department of Special Education and the Department of Private and Business Law in the University of Ibadan. Other juvenile justice and social welfare establishments within the country have a lot to learn from this programme in their quest for a holistic service provision for adolescents within the juvenile justice system.
Strengths and limitation
A major strength of this study is the inclusion of a comparison group. This improves the level of evidence of a higher prevalence of neurological and intellectual disability among the adolescents in the Home. A major limitation however is the fact that the SIT, which was used to measure IQ, does not have an in-built section that addresses specific impairments in adaptive function. This may have limited the interpretation of the scores generated by the instrument as regards disabilities. Although the CGAS score was used to bridge this gap, it is still a subjective measure of adaptive abilities. The fact that SIT is a verbal test with no performance section may imply that participants with subtle communication difficulties may have been at a disadvantage and as such have had a spuriously low IQ scores.
The sample size is small and the results were generated from a single Home. This limits the ability to generalize the findings. Future studies may need to have a larger scale design, involving a higher number of participants and remand centres in the country. Such study may want to include an objective assessment of social skills, which can inform rehabilitation strategies. There is also a need for further in-depth study of the socio-economic and cultural factors that promotes child abandonment in Nigeria with a view to come up with appropriate interventions. In addition, in drawing inferences from this study, it must be acknowledged that this study did not actually study abuse and neglect of children with disabilities but rather drew some conclusions based on previously published literature. While we stronglybelieve that many of the children in the remand home were there because of abuse or neglect, we did not actually study the relationship between neglect/abuse and having intellectual or neurological disability. Future studies may want to build on these limitations in expanding the literature on the relationship between child abuse/neglect and disabilities in this region.