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Pathologising healthy children? Western responses to AIDS-affected children in Africa

28 June 2010

Morten Skovdal

Health, Community and Development Group

Institute of Social Psychology, LSE

m.skovdal@lse.ac.uk

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AIDS-affected children in Africa

Communities and fostering households are struggling to secure the children’s basic needs, including schooling, food and medical care (Nyambedha, Wandibba et al. 2003)

Highlight the perceived cost of the ‘orphan care crisis’ and the need to ‘rectify’ and ‘control’ the children who are growing up without adult support, “vulnerable, scarred, and wary of life” (Kelly 2003:61)

Nyambedha, E., S. Wandibba, et al. (2003). "Changing patterns of orphan care due to the HIV epidemic in Western Kenya." Social Science & Medicine 57(2): 301-311 Kelly, M. (2003). Reducing the Vulnerability of Africa's Children to HIV/AIDS. The Children of Africa Confront AIDS - From Vulnerability to Possibility. A. Singhal and S. Howard. Athens, Ohio University Press: 59-84.

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Mental health research – few examples

Much research explores the psychosocial distress of children orphaned by AIDS• Using a 25-item depression assessment Sengendo and

Nambi (1997) found, that AIDS orphans were sad, felt anger, had little hope for the future and scored high on the depression scale

• Drawing on the Child Depression Inventory, a revised version of the Children’s Manifest Anxiety Scale and Amaya-Jackson’s child PTSD checklist, Cluver, Gardner and Operario (2007) found AIDS orphans in South Africa to have higher levels of depression, peer relationship problems, post-traumatic stress, delinquency and conduct problems than levels reported by children orphaned by other causes and non-orphaned children

Cluver, L. and F. Gardner (2007). "The Mental health of children orphaned by AIDS: a review of international and southern African research." Journal of child and adolescent Mental Health 19(1): 1-17

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Take away messages

Authors acknowledge:• Small sample size, limited evidence, scales not

previously tested in Africa, lacking power Yet, authors recommend:

• The involvement of child psychologists and social workers in schools to offer guidance services

• The need for psychosocial intervention and more large-scale research into the mental health of orphaned children

• Programmes targeting orphans should not only meet their basic needs, but also include psychosocial support with counselling services

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The validity of diagnostic criteria for child disorders cross-culturally is still lacking (Canino and Alegria 2008)

Li et al. (2008) draw on the writings of Western bereavement and grief to present a developmental psychopathology framework for AIDS orphans in resource poor settings

The AIDS discourse is dominated by adult and Western worldviews (of childhood and psychopathology) that interpret and act upon the perceived realities and circumstances of children affected by AIDS• Are perceptions of the mental scarring and developmental

dysfunction of children affected by AIDS merely a social judgement?

Canino, G. and M. Alegria (2008). "Psychiatric Diagnosis - is it universal or relative to culture." Journal of Child Psychology and Psychiatry 49(3): 237-250 Li, X., S. Naar-King, et al. (2008). "A Developmental Psychopathology Framework of the Psychosocial Needs of Children Orphaned by

Perceived vs ‘real’ needs

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Scholarship as a threat to lived realities Interventions and research into the psychosocial

distress of AIDS-affected children may shrink the children’s social reality, forcing them to take on therapeutic identities. • E.g., in order to be supported would need to learn how to

think psychotherapeutically and accept labels such as ‘orphan with PTSD’, ‘traumatised orphan’ or ‘emotionally scarred orphan.’

• Pathologisation can lead to a locally perceived unfair targeting of a single group of children (e.g. AIDS Orphans) and fragment local support networks and cause further marginalisation.

To access international funding, some impoverished African communities have reconstructed how they conceptualise and talk about 'AIDS orphans' - in ways that serve to undermine indigenous support strategies for these children (Meintjes and Giese, 2006)

Meintjes, H. and S. Giese (2006). "Spinning the Epidemic - The making of mythologies of orphanhood in the context of AIDS." Childhood 13(3): 407-430.Summerfield, D. (2008). "How scientifically valid is the knowledge base of global mental health?" British Medical Journal 336: 992-994

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Alternative focus – experiences from Kenya Although a few children may be traumatised, the

majority cope with difficult circumstances through• income generating activities, mobilising social support,

constructing positive social identities Rather than being sick these children are poor We need culturally relevant conceptualisations of

stress and coping in different parts of Africa We need to facilitate psychosocial health, resilience

and local coping strategies We need to listen to what the children’s real needs are

and help them realise solutions through facilitating the forms of social participation that they and their communities are already engaging in• E.g. through social action funds

Skovdal, M. (2009) “Young Carers in Western Kenya: Collective Struggles and Coping Strategies” Ph.D. Thesis, London School of Economics and Political ScienceSkovdal, M. and Campbell, C. (in press). "Orphan Competent Communities: A framework for community analysis and action" Vulnerable Children and Youth Studies

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Social action fund activities with caregiving children in Kenya

Skovdal, M. (2010) “Community relations and microfinance: A case study of caregiving children in Western Kenya” AIDS Care

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Conclusion A growing literature points to the western tendency to

construct Africa as a problem and Africans as victims, often using the language of mental health, rather than acknowledging peoples strengths and coping abilities

Mental health professionals and researchers exploring the psychosocial distress of children affected by AIDS in Africa cannot pretend that their work is value free

I am not disputing the tragedy or horror that many children face, however there is an urgent need for greater recognition of their resilience and resourcefulness

Rather than counselling, many children and their support communities would be better served by community-based and participatory resilience building responses that address the psychosocial challenges experienced by AIDS-affected children in Africa

Skovdal, M. (2009) “Young Carers in Western Kenya: Collective Struggles and Coping Strategies” Ph.D. Thesis, London School of Economics and Political Science