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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.

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