Child, Caregiver, and Teacher Perspectives of Adverse Childhood Experiences and Their Connection to Child Mental Health in Uganda

Background:  Globally, an estimated one billion children experience violence each year (Hillis, 2016).  Types and prevalence of violence are often assessed using the Adverse Childhood Experiences (ACES) framework, which has been linked to immediate and long-term mental health consequences. Although a robust literature evidences the relationship between adverse childhood experiences and poor mental health outcomes, the majority of studies focus on U.S. populations.  A need exists to better understand unique adverse childhood experience within varied cultural and contextual environments, and the potential connection to mental health difficulties. In particular, more qualitative studies are needed, especially those including children’s voices, to understand how adverse experiences are perceived in daily life and influence children’s mental wellbeing. 

Methods:  We conducted a qualitative study to explore children’s, teachers’, and caregivers’ perspectives on childhood adversities, and their impact on child mental health problems in Uganda.  Data collection occurred in February 2018, in two schools in Kampala, Uganda.  Trained, local researchers facilitated four focus group discussions with caregivers (n=22), four focus group discussions with teachers (n=25), and in-depth interviews with primary school students, class 5-7 (n=12).  After transcription and translation, verbatim transcripts were analyzed using framework analysis approach and supported by ATLAS.ti software.  Findings were validated in a workshop with local, Ugandan experts on violence against children.

Results:  Research participants provided varied and nuanced descriptions of adverse experiences and their influence on poor mental health in children. Overall, the data reveal varied and intertwined adverse experiences driving child mental health difficulties, including the combined synergy of environmental (family, school and peer groups), biological, and developmental factors. Mentioned in 19 of the 20 transcripts were experiences of violence (physical and emotional abuse or witnessing violence between parents) and the subsequent negative mental health outcomes on children. Children discussed the dread and worry they felt when they knew they were returning home from school and facing possible personal violence or observed violence.  Other related adverse experiences included the loss of family, which often led to no education and excessive housework, and contributed to poor mental health.  The stress of poverty often arose as an experience and precursor to other traumatic events. For example, children reported a significant stress about school fees being paid on time and worry about the potential trauma of public shaming for late school fees.  Findings also revealed gendered dimensions of adverse experiences.  Girls reported experiencing deep shame and stress over menstruation, which was compounded by subsequent absences from school.

Conclusions and Implications:  The study findings reveal the intertwined nature of adverse experiences affecting Ugandan children’s mental health.  Culturally specific adverse experiences must be considered when interpreting and applying the adverse childhood experience framework across settings. The need remains for more qualitative research to better understand the range of traumas for children and which ACEs are the most pertinent to children’s mental health across settings.  Implications for ACEs studies and practice globally reinforce the need to interpret and address the interconnectedness of adverse experiences and the limitations when considering one apart from another.