Observation Report from Clinical Practice in Ghana: Children and Adolescent Depression

The priority of Ghanaian parents is seeking higher academic attainment for their children. This is associated with the first President of Ghana, President Nkrumah, who stated that Ghanaians should seek first the status of education and everything shall be added unto it. As a result parents compete with each other to achieve the higher status of education for their children. Parents desperately seek help to intervene learning difficulties among school children and adolescents. The aim of this study is to investigate learning disability cases that are seen in a psychological clinic in Ghana using a survey method. The analysis included cases of young people from 3 to 18 years (mean age = 12.7 years, SD = 5.21) that were seen from the year 2011 to 2013. Eighty eight (58%) of the cases were learning disabilities associated with environmental factors whereas 64 (42%) were organic learning disability associated with biological factors. Children experiencing non-organic learning disability conditions were from low socio-economic status families (X2 = 5.95, df = 1, p < 0.05). Findings revealed that high demands of academic performance on these school children manifest as mental health symptoms of depression and anxiety including substance abuse. Practitioners in Ghana are encouraged to assess cognitive functioning of children diagnosed with emotional difficulties in order to get a correct diagnosis and plan appropriate treatment for these children.


Introduction
A learning disability can be simply explained as difficulties in learning. It is a neurological disorder that impairs the brain's capability to receive, process, store and respond to information [1]. Learning disabilities can be categorized into a. Organic -those caused by biological factors and b. Non-organic mainly associated with environmental factors [1]. Organic learning disabilities have severe impact on cognitive functioning. It includes conditions such as Down syndrome, Attention Deficit Hyperactivity, Autism, etc. Organic learning disorders account for a small percentage of learning disabilities among young people [2,3]. Common Learning disabilities among children and adolescents are mainly non-organic caused by environmental factors [3,4]. This implies that a person of at least average intelligence could have problems with cognitive functioning and experience learning difficulties in school. These children have specific difficulties with areas such as reading, comprehension and mathematics disorders. In 2009 learning disability was estimated to be 16% among schoolchildren [2]. However, it is most likely that this rate has increased in 2016. Children of low income families suffer learning disability than their counterparts from high income families [2].

Learning disability in Ghana
Before Ghana's independence in 1957 Ghanaians did not value higher education. Higher education was found mainly among the elites in society. Parents of high socio-economic status perceived education as important beginning from the time Dr. Kwame Nkrumah, the first president of Ghana stated in his speech "Seek first the kingdom of education in Ghana and everything shall be added" [3,5]. Since that time, in addition to western influence, future advancement has been associated with higher academic achievement. Presently, Ghanaian parents expect their children to enter universities in order to succeed in life. Parents therefore seek immediate help for their children with learning disabilities [6]. In Ghana it appears that the majority of schoolchildren receiving help for learning disorders suffer non-organic learning disability [6][7][8]. Learning disabilities among young people in Ghana is likely to be associated with poor nutritional practice, living conditions and inadequate learning support.

Method Young people's consultation at the psychological clinic
The study setting was Progressive Life Center (PLC-Ghana). It is the first private mental health clinic to provide psychological services to Ghanaians. PLC-Ghana since 2001 provides mental health services and community based programmes throughout Ghana. The Centre is situated in Abelenkpe-Accra, the capital city of Ghana. Data was obtained from client records for a period of 3 years. Consent from parents and the young people involved were obtained before the data was analysed.

Tools for data collection
Young people included in the survey were those who had complete records on the following: Client's profile including demographic information, psychologists intake assessment form, milestone development form; psychological tests including Standard Progressive Matrices [9], Coloured Progressive Matrices [9], Children Depression Inventory [10,11], Multidimensional Anxiety Scale for Children [12] and also referral forms containing physician's diagnosis. Conditions which were categorised as organic or biological included Turner's Syndrome, Klinfelter's Syndrome, Down Syndrome; birth complications associated with organic brain factors were maternal alcoholic intake during pregnancy, smoking, viral and bacterial infection in pregnancy, anoxia-lack of oxygen, low birth weight, etc. The environmental factors which were identified through the milestone development assessment of the children include the absence of any neurological complications such as poor nutrition, substandard education, poor environmental hygiene and overcrowding, untreated malaria resulting in series of convulsions. Socio-economic status was determined with the affordability of service costs. Children whose parents afforded the service cost were categorised to the higher strata of socio-economic status whereas parents who received a scale down of cost were put in the lower strata of the socio-economic status.
Three quarter of Ghanaian parents who reported to the clinic with their children's Learning Disability Issues did not understand the causes of learning disability. Parents simply reported that their children did not perform well in school. Some of the parents attributed that to superstition. The ages of young people whose parents arranged clinical consultations for, ranged from 3 to 21 years. About half of these young people had repeated their class. Parents allowed school teachers to give physical punishment to children with learning problems though physical punishment is prohibited in schools. Parents ignored the physical punishment policy in school [7] and reinforced teachers to cane or use shaming techniques to control learning problems with the assumption that the children with low school performance are lazy.
Pressure for high academic performance by parents and teachers combined with the learning difficulties experienced by children, produced extreme stress among the children. The pressure from academic demands on these children by parents also increased when there was comparison to peers and siblings who were performing better in school. These frustrations resulted in negative behaviours among children.

Findings
It has been identified through clinical practice in Progressive Life Center that the following behaviours shown by children may signal learning difficulties: depression, anxiety in the form of school phobia, substance abuse and sexual behaviours. Consultations with clients at PLC, a psychological services clinic from 2011 to 2013 showed that 90% of children who were brought to the clinic with learning problems identified by parents and teachers also showed psychological symptoms such as depression, anxiety and body image dissatisfaction. Out of 152 cases of learning difficulties, 64(42%) suffered organic learning disability while the majority 88 (58%) suffered non-organic learning disability. Children experiencing non-organic learning disabilities were mainly from low-socioeconomic status families (Table  1). During the same period, young people (mainly adolescent boys) whose parents brought them for substance abuse treatment, the psychological assessment findings of these children revealed learning difficulties in school.
The following is a clinical example of a child's frustration: Parent's report "My child is always drawing at home instead of reading other subjects. She is not performing well in school" Teacher's observation "This child hides a paper under her desk and scribble during lessons. I found that the child has been drawing nice pictures" Parent's response "I have warned my chid not to draw. Please ensure she doesn't draw in class" Child's Reaction via Parents Observation "Child spends time alone in the room drawing pictures. She draws sad faces" Child's Verbal Assertion in Clinic "I want to be an artist but my parents become angry anytime they find me drawing. They want me to follow my father's footsteps and become a lawyer instead".
Children in this kind of situation above who don't have learning difficulties associated with either organic or environmental factors also suffer psychological symptoms as a result of parental pressure for higher academic performance associated with vocational choice. The underlying factors of young people's psychological symptoms can only be revealed through a holistic psychological assessment.
Among school children and adolescents mental health symptoms and learning difficulties are closely related and influence each other in a bi-direction [8]. For clinical practice in Ghana, when children are reported to have mental health symptoms, The Child Psychologist should include questions concerning learning difficulties in school and also do an assessment of cognitive functioning. Some of the popular cognitive functioning tools which have been standardised in Ghana and commonly being used successfully to determine cognitive functioning among young people is the Raven's Progressive Matrices [9]. On the other hand, the Children Depression Inventory [10,11] and Multidimensional Children Anxiety Inventory [12] have been successfully used to confirm emotional problems among school children and adolescents in Ghana [6].

Conclusion and Recommendation
In Ghana, future success of children is highly associated with higher academic achievement. Learning difficulty is a main factor that produces emotional symptoms among Ghanaian school children and adolescents. Schoolchildren and adolescents brought to a mental health clinic to receive psychological intervention for learning disabilities tend to show emotional and behavioural difficulties as well. It is likely that mental health symptoms may be caused by difficulties in cognitive functioning. Similarly, mental health problems in turn might impair learning. Practitioners in Ghana are encouraged to assess the cognitive functioning of young people diagnosed with mental health and behavioural symptoms. This is particularly important for crosscultural practice in Ghana. Children categorised to the low strata of socio-economic status experienced non-organic learning disability; this is a learning difficultly associated with environmental factors. It is likely that inadequate environmental provisions are contributing to their academic problems. This finding may explain why poverty has been associated with learning disabilities [2]. Though the findings of this survey is based on consultations in one clinic it shows the form of learning disability cases in Ghana and how it can be diagnosed through emotional symptoms. It is recommended that future studies do a systematic survey to examine the link between learning difficulties and behavioural problems in children and adolescents in Ghana.