That South Africa has unusually high levels of interpersonal violence is clear from the country’s crime statistics and regular news reports about violent crime. The knock-on effects on the mental health of people affected are less easy to quantify.

There is, however, evidence that the country’s high levels of violence are contributing to high levels of mental health conditions. In some cases, experts say, the shadow cast by violence can be very long, with exposure to violence and trauma in childhood being associated with mental health problems in adulthood.

Local research published recently shows an association between exposure to violence in childhood and mental health problems later in life. (Photo: Nasief Manie / Spotlight)

The latest piece of evidence comes from a study on the impact that traumatic events in adulthood and adverse childhood experiences (ACEs) have on depression, anxiety and stress scores of outpatients receiving psychiatric care at two public mental-health treatment facilities in Johannesburg. The researchers found that ACEs – which can include sexual abuse, physical abuse, neglect and interpersonal violence – are “highly prevalent in low-resource settings and associated with adverse psychological outcomes”.

According to Dr Michael Galvin, one of the study authors, they asked participants about their experiences based on a list of 10 forms of ACEs, noting that these 10 are among multiple possible ACEs that may not have been included in their list.

“The first one,” he tells Spotlight, “was about verbal abuse by a parent; the second was with physical abuse by a parent; the third was sexual abuse by someone in the household; fourth was emotional neglect; fifth was sort of material neglect, [meaning] not having enough to eat, dirty clothes; six was if your parents were separated or divorced; seven was if you witnessed usually gender-based violence or domestic abuse; eighth was if there was drugs or alcohol used in the household when you were a child; ninth was if there was mental illness or suicide in the household when you were a child; and then the 10th was incarceration of people in your household while you were a child.”

Read more in Daily Maverick: Depression, anxiety and childhood trauma: South African study explores links, prevalence and who’s most at risk

Galvin says they interviewed 309 patients at two psychiatric units in two public hospitals in Johannesburg. He is cautious about generalising the study findings to the prevalence of ACEs in South Africa as a whole, but concedes that many studies (longitudinal and also systematic reviews) – mostly from developed countries – have highlighted the link between ACEs and mental health outcomes.

He also stresses that the study looked not only at what had happened during childhood, but also at adult traumatic experiences, and the impact of both on adult mental health.

One of the most common and most serious underlying causes of adverse childhood experiences is child sexual abuse, experts say. (Photo: Black Star Images / Spotlight)

“So it looked at the relationship between adverse childhood experiences and traumatic events that have occurred during adulthood, and how those two together impact adult mental illness. So, ACEs are only half of the equation [with] the other half being traumatic experiences during adulthood, and we had a whole list of adult traumatic experiences that were different from the ones experienced during childhood.”

Among these, he said, were, lack of medical care; extended periods of homelessness; imprisonment and separation from family; serious injury from a fight; rape; being a victim of a violent attack; and murder of a family member. There was also a category for study participants to add other experiences.

According to another study co-author, Dr Aneesa Moolla, their findings “of elevated risks of poor mental health outcomes associated with ACEs are consistent with previous research indicating that ACEs have cumulative negative impacts on physical and mental health during adulthood”.

Moolla tells Spotlight that despite South Africa “being a developing country and, [given that] a lot of the studies being done are in developed or first world countries, it basically still shows the same thing – that this is a worldwide thing. It’s like a one-in-three kind of thing, but obviously, here, there are many more undiagnosed people walking around or seeking different kinds of healthcare as opposed to normal medical care”.

Children queue to wash their hands before sitting down for their meal. (Photo: Black Star / Spotlight)

Moolla says studies have shown that in other parts of sub-Saharan Africa, youths who have experienced trauma frequently show increased aggression, anger, depression, hopelessness, withdrawal and social isolation. She says in South Africa, while few studies have examined ACEs among local populations, the few that exist have found high rates of ACEs. She referred to one study that looked at ACEs in a cohort of children in Soweto that found that 35% had four or more ACEs.

Adverse childhood experiences and mental health

According to Galvin, one of the most common and most serious underlying causes of ACEs is child sexual abuse. “And then there’s also a lot of physical abuse,” he says. “Then also neglect – so not taking care of a child may lead to the child experiencing deprivation of food, water, medical care, anything considered essential.”

Some mental health practitioners working closely with mental health issues and survivors of trauma agree that childhood trauma can impact mental health in adulthood.

Marthé Kotze-de Beer, director of the organisation Healing Leaves, says: “When we talk about ACEs now, we are talking about any potentially traumatic events that take place within the developmental childhood years. What causes ACEs to be so potentially harmful is the fact that they take place during the time when a child’s brain is still developing.”

Healing Leaves is a Free State-based organisation that works on restoring dignity to those who have experienced trauma, adversity and shame through community-based relational intervention programmes.

Kotze-de Beer says: “This intense stress, especially without proper support systems in place, has the potential to negatively affect the way in which a child’s brain will develop and how their body will learn to respond to stress, and this impacts their mental and physical health throughout their lifetime.”

A young child runs home after receiving a meal from a pop-up soup kitchen. (Photo: Black Star / Spotlight)

She notes a recent study conducted by the Wits/Medical Research Council Developmental Pathways for Health Research Unit (DPHRU) that suggests that around a quarter of people in South Africa suffer from probable depression, with significant variation between provinces. The study shows a clear association between the respondents’ ACE scores and their likelihood of experiencing both depression and anxiety.

That association remained after adjusting for sociodemographic confounders, which suggests that the relationship may well be causal. In this regard, the DPHRU researchers write that their finding is “in line with previous literature stating that the early years of life are crucial in determining mental health outcomes in later life”. The study interviewed 3,402 people from across the country.

According to Kotze-de Beer, the best data in South Africa on the prevalence of ACEs comes from the Optimus Study, which was conducted among high school-aged learners across South Africa in 2016.

“The study found that one in three South African children have experienced some form of sexual abuse. 15.1% of respondents reported experiencing some form of neglect, which is slightly lower than the global average of 16.3%,” she says. “34.8% of respondents reported having experienced physical abuse, which is higher than the global average of 22.2%.”

“It is also worth noting that many of the events that constitute ACEs are still heavily stigmatised and have a great deal of shame around them, so reporting may be lower than actual prevalence levels, which means we do not know the whole scope of the problem,” Kotze-de Beer says

Types of ACEs 

“Stress from an ACE is different from the everyday stress that children experience,” says Dr Alicia Porter, a psychiatrist working in the private sector. Porter says ACEs are significant in that they are linked not only to mental illness in adulthood but also to chronic physical health conditions and substance abuse.

“ACEs can lead to health problems like asthma, diabetes and heart disease. They can also impact behaviour, learning and mental health,” she says. “They [ACEs] can be categorised into three groups – abuse, neglect and household challenges or dysfunction. Expanded ACEs consist of additional items that measure exposure to bullying, community violence, neighbourhood safety, racism, [or] living in foster care,” she says.

Another private sector psychiatrist, Dr Terri Henderson, notes the intergenerational effects of ACEs.

Even in 2023, infants under five in the Free State are still dying from a lack of healthy food. From April to June this year, 21 children in the province died of severe acute malnutrition. (Photo: Black Star / Spotlight)

“Trauma experienced by a parent that is untreated will affect their ability to parent and, therefore, their children are more likely to be exposed to adverse events. So you often see that parents who have had trauma or a very difficult childhood have had no support, no intervention. Their children are compromised in that they’re unavailable as adequate parents,” she says.

“There’s a strong sense of what we call cross-generational trauma. Where trauma is not treated and therefore transferred to children. And so it goes through the generations.”

According to Henderson, if one doesn’t have a successful adolescence, then one is unlikely to have successful adulthood unless there is an intervention. “So individuals are less likely to achieve at school, are less likely to have tertiary education, and therefore less likely to achieve professionally and have opportunities in the workplace,” she adds.

Violence as a trigger

The experts Spotlight spoke to see high rates of violence (experienced as a child or an adult) as a risk or contributing factor to mental health conditions.

Kotze-de Beer, for example, says that while violence is not the only aspect negatively affecting the mental health of people in South Africa, reducing the rates of violence, especially against women and children, would have a marked effect on rates of mental illness.

Read more in Daily Maverick: South Africa’s staggering intimate partner violence stats aren’t shifting – here’s what we can do about it

What to do?

According to the authors of the recent study at the two Johannesburg mental health facilities, part of the solution is “to strengthen and scale innovative combination interventions that holistically address the needs of people in low-resource settings”. 

Both Moolla and Galvin note that mental healthcare provision in South Africa should include more psychosocial care for psychiatric patients – currently, most patients receiving treatment at public facilities receive little to no counselling or therapy because of monetary constraints.

Moolla says communities often witness child neglect but ignore it. She says it will help to make communities more aware of what traumatic events are and what the reporting channels are.

According to the Optimus study, one in three South African children have experienced some form of sexual abuse and 15.1% of respondents reported experiencing some form of neglect. (Photo: Nasief Manie / Spotlight)

“I think it helps [to get] outside help and links to where the services are available. They are there. I think it’s just people aren’t using them, or they don’t even know how to access them.”

In this respect, she says, community healthcare workers can play a big role in communities, and they can be a safe source of information.

Porter says it is important to strengthen families and to “promote social norms that protect against violence; positive parenting practices;[and] prevention efforts involving men and boys”.

She says it can also help to connect children with activities and caring adults, school or community mentoring programmes and after-school activities. She agrees with Moolla that it can help to educate people about ACEs and intervene to ameliorate immediate and long-term harms through therapy, family-centred treatment and treatment of substance use. Early learning programmes and affordable preschool and child-care programmes can also help, she says.

Read more in Daily Maverick: SA’s new mental health plan and the problem of stigma

Earlier this year, the annual Child Gauge indicated that child and adolescent mental health services in South Africa are in crisis – mostly due to inadequate resources. (Photo: Nasief Manie / Spotlight)

Kotze de-Beer says the best way for adults to raise resilient and mentally healthy children is to start by healing and processing their own traumas.

“Adults who have not recovered from their own traumas are more likely to be mentally ill, struggle with substance abuse and have dysfunctional relationships. It is also vitally important that we educate parents, teachers and other community members about trauma. Many of the ‘problem’ behaviours we see in children within our communities are not signs that today’s children are bad or that they are not receiving enough discipline, [but] rather that many of these behaviours are signs of trauma,” she says.

“Recognising this difference is the key to how we interact with these children. Treating them as ‘bad kids’ and wanting to shun or punish them is not going to help heal their trauma.”

She says what is more helpful is “understanding the causes of trauma, knowing what signs and behaviours to look out for, and learning practical ways in which to support these children and promote their healing”. DM

This article was published by Spotlight – health journalism in the public interest.