This Cambridge Life

Children in West Africa with cognitive difficulties are going undiagnosed because the tests used to assess their mental health are based on Western norms. Kwabena Kusi-Mensah is working with communities in Nigeria and Ghana to develop assessments that are culturally appropriate.

Like many young students entering medical school I initially wanted to become a neurosurgeon. But the reality was I just found surgery a bit too routine. At first it was exciting but after a while it became like cutting hair.

What really fascinated me was the stories of the patients I met during my psychiatry rotation. The idea that something as fundamental as reality could be distorted in someone else’s experience intrigued me.

There was also a harrowing side to the mental health wards. When working as a foundation year doctor in a resource-deprived area in the north of Ghana, mentally ill people were brought into the hospital in chains having been transported from prayer camps [informal privately run faith-based establishments operated by Christian, Muslim or traditional healers].

It was heart-breaking to see children known as ‘spirit children’ abandoned. These children likely had intellectual disability, autism or some sort of congenital or neurodevelopmental disorder. But their communities believed they were cursed. It was not uncommon to hear of children that clearly had undiagnosed Attention deficit hyperactivity disorder (ADHD), being repeatedly punished in school or at home for being “naughty.”

I thought that something must be done about this. I went to Nigeria and took a master’s degree in child and adolescent mental health. I absolutely loved it. But the more I became exposed to the field, the more problems I discovered that needed to be solved.

In West Africa many people don’t realise that children can suffer from mental health problems – they feel that children are too care-free to do so. This means that often children go undiagnosed, which impacts on their educational attainment and wellbeing, as well as having wider implications for society. We have a lot of work to do in terms of advocacy and public education.

We lack clinicians trained in child and adolescent mental health (CAMH) – I’m one of only five psychiatrists trained in CAMH serving a population of about 17 million children. Consider also that more than 50% of the population in West Africa is under 18 years old. Millions of children are falling through the cracks, not because they are “stubborn” or “lazy” or “dumb” but because their brain is processing things differently.

We desperately need more researchers – people with the tools not just to ask the right questions but to answer them too, which is why I’m here in Cambridge. Empirical evidence is essential if we want to persuade our policy makers that investment is needed to build capacity and attract young talent to the field.

When I arrived in Cambridge, I faced a dilemma. I was surrounded by people doing amazing things at the cutting edge of psychiatry. I was tempted to change my project idea and do something involving MRI scans or biogenetics – something that would make me an expert in my field – perhaps give me a Nobel Prize!

But I couldn’t turn my back academically on my people. Following sage advice from my supervisor, Professor Andrew Bateman, I reflected soberly and thought: how many MRI machines are there in Kumasi? Who am I going to help practically when every day at my clinic we are facing bread and butter issues?

A major problem in West Africa is that cognitive assessments are based on Western norms, impairing diagnosis and treatment. For example, I can think of an item assessing adaptive functioning which asks if a child can operate a washing machine or knows how to type a paragraph on a laptop, but this technology might not be available to a child living in rural Ghana. Another item on a tool assessing autism asks if a child can maintain sustained eye contact, but in many parts of West Africa it is considered disrespectful for a child to look an adult in the eye.

It’s not enough to translate items on assessments. Someone might understand the words themselves but not the concept. You need to be on the ground, speaking to people to check that they understand the question.

I wanted to create a culturally appropriate assessment to measure indicators of brain functioning. Specifically, I focused on executive functions and adaptive functioning. Executive functions are linked to planning, goal setting and decision making. Adaptive functioning is related to how well someone can deal with the demands of everyday life.

I selected the two tests most used in low- and middle-income countries to measure executive functions and adaptive functioning. I carried out focus group discussions with end users – teenagers aged 13 to 18 years old in both rural and urban communities in Ghana and Nigeria, in addition to their parents and local practitioners.

These conversations revealed the importance of developing assessments alongside the people who would be using them. For example, even a seemingly simple word like “trouble” (used in the item “I have trouble sitting still”) was understood in wildly different ways by teenagers who often took it to mean they got into trouble with their teachers.

I found that parents and teachers consistently used words suggestive of character flaws to describe children with executive function difficulties. Aside from highlighting that we have advocacy work to do, this gives us a clue as to how we begin to find these children with undiagnosed executive dysfunction and give them the help they need.

Interestingly, emerging from the conversations was a term called efie nyansa (in my native Akan language) which I’d literally translate as ‘home sense’. My hunch was that home sense could relate to executive function. To investigate this, I carried out further interviews with parents, mental health practitioners, teachers, traditional rulers and local elders.

Home sense appears to be related to the goal-setting process and responsible decision-making that considers the collective good of the community. There’s also a strong moral aspect to it. It seems parallel to what, within the western conceptualisation of executive function, would be called meta-cognition which is essentially thinking about thinking. Meta-cognition is theorised to be the top level of executive function. Measuring home sense could be a culturally appropriate way to assess this level of executive function in West Africa.

In the future I hope to secure funding or a postdoctoral position to build on the work of my PhD and develop a cognitive assessment tool for children in West Africa. I’d like this to be a test that could be carried out relatively quickly on a mobile phone which would help address our lack of resources and mean we could carry out assessments in rural settings.

Conducting research and training clinicians in research is key. I’d like to see regular surveying to assess the mental health needs of our communities. I’d also like to help establish a CAMH clinical training programme combined with a research MPhil or PhD.

When I first set out to train as a psychiatrist lots of people discouraged me saying: “there’s no future in the profession” or “you’ll become like your patients.” The reality was there were not many role models, particularly in mental health research, to look up to (although I am grateful to those few local mentors who did spur me on to come into this field).

Often people just need to see an example of what they can be to expand their horizons – you're only as good as how far you can see yourself. I hope I too can be a role model to young West Africans.

_{Dr Kwabena Kusi-Mensah is a Commonwealth Scholar and PhD Student with the Department of Psychiatry and is a member of Darwin College. He is a psychiatrist at the Komfo Anokye Teaching Hospital in Kumasi, Ghana.} 

Published 23 May 2022
With thanks to:

<sub>Kwabena Kusi-Mensah

The participants of the study who kindly gave permission for their photographs to be used for research promotion purposes.</sub>

_{Words:
Charis Goodyear}

_{Photography:
Bernard Acheampong
Lloyd Mann
Tosin Obuene
Tomisin Ogunmola
David Owusu
Emmanuel Waters Aidoo
Centre for Child and Adolescent Mental Health, University of Ibadan, Ibadan Nigeria
Kintampo Health Research Centre, Kintampo Ghana}

_{The text in this work is licensed under a Creative Commons Attribution 4.0 International License}