childhood behavior disorders in ambo ii

8/13/2019 Childhood Behavior Disorders in Ambo II

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c tu P s y h i u t r cund 1999. 100. 92 97Prinrcrl in UK. Al l rixhts rrsurved Copyrrght Munkbguurd I Y Y YCl A S Y C H l A T R l C AS C A N D I N A V I C AI S S N 0902-4441

Childhood behavioural disorders in Arnbodistrict, western Ethiopia. I. PrevalenceestimatesTadesse B, Kebede D, Tegegne T, Alem A. Childhood behaviouraldisorders in Ambo district, western Ethiopia. I. Prevalence estimates.Acta Psychiatrica Scand 1999: 100: 92-97. 6 Munksgaard 1999The study was conducted between September 1994 and May 1995 inAmbo district, western Ethiopia. The prevalence of childhood beha-vioural disorder in children was found to be 17.7 . Behavioural disorderwas found to be more common in boys than in girls. The prevalenceincreased with age. The most frequent symptoms reported were headacheand nervousness. The least prevalent symptom was stealing things fromhome. As age increased, the risk of behavioural disorder increased. Theincrease in risk was statistically significant in the 15-year-old group whencompared to the age group 5-7 years (adjusted Odds Ratio, OR= 1.89,95 confidence interval, CI: 1.08-2.85). Childhood mental disorder wasstatistically significantly associated with parental age and with parentalmarital status. Children whose parents were 524 years old had a higherrisk of having mental disorders (OR: 2.03, 95 CI: 1.30-3.16) comparedto those children whose parents were in the 45+ age group. Childrenwhose parents were categorized as unmarried, divorced, separated, orwidowed had a higher risk of having behavioural disorders (OR: 2.22,95 CI: 1.70-2.91) than children whose parents were married. There wasa statistically significant association between parental psychoneurosisand children's behavioural disorders; children whose mothers hadpsychoneuroses were at a higher risk of having behavioural disorders ascompared to those whose mothers had no psychoneurosis (OR: 1.78,

B. Tadesse , D. Kebede ,T. Tegegne3, A. Alem3Oromia Heal th Bureau, Addis Ababa. Departmentof Communi ty Heal th, Facul ty of M edic ine ,Universi ty of Addis Ababa, and 3AmanuelPsychiatr ic Hospi tal , Addis Ababa, E thiopia

Key words. chi ldhoo d m ental disorders;arevalence; EthiopiaBelayneh Tadesse, Oramia H eal th Bureau,O.0. Box 22174, Addis Ababa, E thiopia

IntroductionChildhood mental health programmes are not givensufficient attention in most African countries. Thisneglect can be attri buted, among other things, to thelimited information about the extent of childhoodbehavioural disorders, the inadequate orientation ofhealth workers to mental health problems, and theresulting indifference or negative attitudes towardthese problems (1).Although the information on childhood beha-vioural disorders in developing countries is verysparse, there is evidence that the rate of behaviouraldisorders in children seen in primary care facilitiesmay, in fact, be similar to the rates in developedcountries (2, 3 .Surveys of general populations show that theprevalence of persistent and socially handicapping92

mental health problems among children aged 3-15years in developed countries is about 5-1 59'0. Morelimited data from developing countries suggest aroughly similar rate 4). n Africa, a study usingthe Reporting Questionnaire for Children (RQC)reported tha t 17% of 545 children aged 5 to 15 yearswho a ttended primary health care services in ruralSenegal were suffering from some form of emo-tional problem, behavioural disturbance, or neu-ropsychiatric disorder (5). In Kenya, Kangethe andDhadphle 6) screened 303 children aged 5-15 yearsusing the RQ C and found that 20 of the childrenhad clinically significant and definable psychiatricdisorders. A WHO collaborative team did a studyto measure the frequency of behavioural disordersin 925 children attending a primary health careservice in four developing countries. They used the


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Prevalence estimatesRQC with a cut-off point 0/1. They determined theprevalence rates of behavioural disorders to be 12%in Sudan, 15% in the Philippines, and 29% inColombia (7).In Ethiopia, very few community-based studieshave been done to estimate the prevalence of mentalillnesses in children. In 1968 Giel et al. (8) studied381 children aged 0-20 years using psychiatricinterviews and found a prevalence of 5.2%. In 1989another survey utilizing the RQC and the CBPQ(Childhood Behavioural and PsychologicalQuestionnaire) interviewed 860 children aged 3-12years and found rates of 21.4% for boys and 25.2%for girls (9).

We report here on the results of a community-based survey of childhood behavioural disordersusing the RQC in a rural population of westernEthiopia.

Material and methodsThe study was conducted between September 1994and May 1995 in Ambo district, western Ethiopia.

Ambo district is one of the 23 districts of theWestern Showa administrative zone. The district islocated about 120 km to the west of Addis Ababa,the capital of Ethiopia. Ambo district has 136 sub-districts, of which eight are urban sub-districts andthe rest are peasant associations. The population ofthe district is estimated to be 198461, of which17.3% live in the urban area and 82.7% live in ruralareas. The male-to-female ratio in the district is86: 100. About 13% of the population are 5-1 5 yearsold. Ninety percent of the population speakAmharic, and about 98% are OrthodoxChristians. Approximately 95% of the populationare from the Oromo ethnic group. There is onepsychiatric nurse working in the district hospital

The instrument used to estimate the prevalence ofmental disorder in children was the ReportingQuestionnaire for Children (RQC) developed by aWHO expert committee on mental health fordeveloping countries. The English version of theRQC was translated into the Amharic language bythree psychiatrists independently. Back-translationinto English was done by another psychiatrist whodid not know the original version. An Amharicversion of the Self Reporting Questionnaire (SRQ)was used for collecting data on mental distress incaretakers of the children enrolled in the study. TheSRQ has been validated and used in several studiesin urban and rural Ethiopia (1 1, 12).We employed interviewers who had completed12th grade and who spoke Oromifa (the locallanguage) and Amharic (the national language).

(10).

Fifteen male and 15 female interviewers wererecruited. Two male supervisors were recruited forsupervising the interviewers. Supervisors and inter-viewers were trained for three days. To pretest thequestionnaire, 10 randomly chosen parents orcaretakers were interviewed from one of the sub-districts in a district not chosen for the main study.From each household, parents or caretakers wereinterviewed. In cases where both father and motherlived together, the RQC was used to interviewmothers abou t their children, and the SRQ was usedto ask them questions about themselves. In cases ofrefusal to be interviewed or when a child was notavailable in the sampled household, the nexthousehold was chosen. Household numbers werein the order of +1, -1, +2 or -2 of the original housenumber chosen.ampling procedure. The source of the studypopulation was all children aged between 5 and 15years, living in the accessible sub-districts. Thesampling units were the households in the district. Asample size large enough to detect the prevalence ofmental illness in children was calculated on the basisof prevalence estimates for behavioural disorders indeveloping countries.The information about the population in ruraland urban sub-districts was obtained from districtmunicipality and agriculture departments. The ruralsub-districts were stratified in terms of accessibilitywith regard to transportation. Thirty clusters (sub-districts) were selected out of the 36 accessible ruraland urban sub-districts in proportion to populationsize. All eight urban sub-districts were included inthe study. For household selections, a total numberof households in the clusters were divided to get thevalue N (the sampling interval). Both rural andurban area households from each sub-district werechosen by starting from randomly selected house-holds in the sub-district and continuing with everyNth household until 50 households were chosenfrom each cluster.It was possible to obtain interviews from 1440households and the response rate was 96%). Fromthese households, 3001 children and 1400 mothersor caretakers participated in the study.Exclusion criteria for households were: 1. Therewas no child between 5 and 15 years old in thehousehold. 2. Refusal to participate. 3 . Caretakerswere not available for interview during two visits. Ineach of these cases, replacements were made asstated above.After the respondents were identified, the inter-viewers first read out a note to inform them of thepurpose of the study, the type of interview, and howit was to be conducted, and the potential benefits forthe respondents and their children. Then consentwas solicited. After obtaining consent, the inter-

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viewers read aloud each question. If informantsexpressed any doubt when deciding a yes or noanswer, the interviewer repeated the question with-out any form of further explanation.Childhood behavioural disorder was defined as achild who scored at least 1 item from the 10 items inthe RQC. This cut-off level was determined from avalidation study of the RQC reported elsewhere

Parental mental distress was defined as a parentscoring a t least 8 yes answers ou t of the 20 neuroticsymptoms or at least 1 yes answer out of the 4psychosis symptoms in the SRQ. This cut-off levelon the SRQ was determined based on examinationof studies that have employed the instrument insurveys in urban and rural Ethiopia (14, 15).Data were entered and analysed using EPI- INFOversion 5.0 program and multivariate analysis wasconducted using Statistical Analytic System (SAS)version 6.03 program.To evaluate the association of several potentialrisk factors with mental illness in children, oddsratios (OR) and 95% confidence intervals (CI) wereestimated. To adjust for confounding, a logisticregression model was employed. Test for trend wascalculated by including the adjusted odds ratio as acontinuous variable in a logistic regression model.Test of statistical significance was put at 0.05 level.

1 3).

ResultsA total of 1400 households and 1400 mothers o rcaretakers was included in the study, and all themothers responded about the mental status of a

Motal with dlsorderSex o f child ] i4aleFemaleo f child5 - 70 - 1 0I 1 - 1415+

RQC symptoms responded to:Abnormal speechSleeping poorlyFits or fallingFrequent headachesStealing things f rom homeNervousness 4.1Backwardness

ot playing with othersWetting or soiling on eself 110 15 20 25PercentFig. I Socio-demographic characteristics and RQCsymptoms.

total of 3001 children. Of these, 49.4% were male.Sixty percent of the mothers were 35 years of age orabove, 29% were between 25 and 34, and 11Yn wereunder 25 years of age. Only 1.6% of the motherswere unmarried.Among the children, 52.5% had completed 1-6grades, and 9.8% had completed 7-9 grades.Among parents, 58 were illiterate, 19% hadcompleted 1-6 grades, and 23% had completed7-9 grades.

Over 45% of the households had an averagefamily size of 5-7, and 26.3% had an average familysize of 2-4 . Parents (90.1YO ad an income less than100 birr (approx. US 20) per month. Thirty-ninepercent were housewives, 20% were farmers, 14.3%were daily labourers, and 9.5% were skilled workers.The majority (79.5%) were from the Oromo ethnicgroup; 16.9% were from the Amhara ethnic group.Orthodox Christians constituted 92%)of the house-holds and Moslems 2%.Of the children, 17.7% had at least 1 of the 10symptoms described by the RQC. Behaviouraldisorders were found to be more common in boysthan in girls. The prevalence increased with age. Themost frequent symptoms reported were headacheand nervousness. The least prevalent symptom wasstealing things from home (Fig. 1).To evaluate the role of potential risk factors forchildhood behavioural disorders, 302 (2 .6%)households with at least one child with beha-vioural disorder were compared with the rest ofthe 1098 households that did not have any childwith a behavioural disorder. Although, in thecrude analysis, boys appeared to have a higherrisk of having behavioural disorders than girls,the association was not statistically significantand decreased further when other variables wereadjusted for in a multivariate model (Table 1). Asage increased, the risk of behavioural disorderincreased. The increased risk was statisticallysignificant in the 15-year-old group when com-pared to the age group 5-7 years. Adjustment forpotential confounding variables gave similarresults, as shown in Table 2. Children who hadsome formal school education were at slightlyhigher risk for behavioural disorders thanchildren who had no formal education, butthis difference was not statistically significant.Birth order was not associated with behaviouraldisorders.There was no significant association betweenchild behavioural disorders and parental income,family size, education, occupational status, ethni-city, or religion.Childhood behavioural disorders were associatedwith both parental age and marital status. Childrenwhose parents were 24 years of age or younger were

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Prevalence estimatesTable 1 Demographic correlates o f childhood behavioural disorders among children 5 to 15 years of age in Ambo district, western Ethiopia. 1995

Characteristics Population CasesSex

MaleFemale5-78-1 011-1415

EducationIlliterate1-6 grades7-1 2 grades

Birth order1St2-4

5

Age

Total

691709

41041 8480

92528734138644508248

1400

1601427985

10830

11515235

14410355

302Reference group

at a higher risk of having behavioural disordersthan children whose parents were in the 45+ agegroup. Children whose parents were categorized asunmarried, divorced, separated, or widowed had ahigher risk of having behavioural disorders thanchildren whose parents were married. The oddsratios of behavioural disorders with parental ageand marital status did not alter appreciably whenpotential confounders were controlled for in amultivariate model (Table 2 ) .The prevalence of mental distress in the motherswas 23.9%~ wenty-two percent of the mothers hadprobable neurosis and 4.7% had probable psycho-sis.There was a statistically significant associationbetween parents' report of mental distress and theirchildren's behavioural disorders. Children whosemothers had mental distress were at a significantlyhigher risk of having behavioural disorders thanchildren whose mothers had no mental distress.This association persisted even when potentialconfounding variables were adjusted for (adjusted

N o statistically significant association was foundbetween mental distress in the fathers and children'sbehavioural disorder.

O R: 1.74, 95Yn CI: 1.30-2.32).

DiscussionW e have shown that a large proportion of thechildren in this study have behavioural disorders.W e have followed several procedures to ensure thatthe results are valid. In order to minimize theintroduction of possible bias during data collection,data collection was carried out by persons who werenot health care professionals and who were givenappropriate training. The sample size was large

Odds ratio Odds ratiocrude (95% C Adjusted (95% Cl)

1 2 01001001701.222 041 .oo0 941 221 oo0 880 98

(0 92-1.57)

(0 75-1.53)(0 87-1 71)1 19-3 44)

(0 6-1 41)(0.83-2 03)

(0.54-1 32)(0 76-1 65)

1121001001 021 1 51 8 91000 871301001 0 51 0 8

(0 80-1 40)

(0 62-1 30)(0 77-1 60)1 08-2 851

(0 70-1 301(0 70-2 0 1 )

(0 50-1 40)(0 45-1 35)

enough. In all households, mothers were designatedas the respondents who provide information abouttheir children's behavioural status so that there wasa consistency among respondents, at least by sexpattern. Because the items were unambiguous anddescribed recognizable behavioural and develop-mental problems, it was not necessary that a parentbe literate to respond. In order to minimize thepossibility of selection bias, all children in ahousehold who were between 5 and 15 years oldwere included in the study. Multivariate logisticanalysis was also employed to adjust for potentialconfounders.The prevalence of behavioural disorders found inthis study approximates those from other studiesthat have employed the same instrument.Community surveys in developed countries havefound prevalence ranging from 3% to 15Yn (4) . In astudy that used a cut-off point of 2 or more items inrural Senegal, prevalence was 16.9'31 5 ) . Using thesame instrument and a cut-off point of 1 or moreitems, Giel et al. reported a prevalence of 12% inSudan, 15% in Philippines, 23'Yn in India, and 29% inColombia (7). In Kenya, the prevalence was 30%6 ) . The higher prevalence (24%1)ound in Ethiopiaby Mulatu (9) han the 17.7% we found in our studycould be due to differences in the age groupsstudied, the use of different methodologies, thediffering proportion of urban children in the twostudies, or due to socio-cultural differences betweenthe communities studied.The association between childhood behaviouraldisorders and the child's age, the maternal age andsingle parenthood is also consistent with the resultsof other studies in developing and developedcountries (3 , 4, 9).

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Tadesse t al.Table 2 The distribution of childhood behavioural disorders, according to parental characteristics, among children 5 to 15 years of age i n Ambo district. western Ethiopia. 1995

CharacteristicsOdds ratio Odds ratio

Population Cases Crude (95% CI) Adjusted (95% CI)Age1 2 4

25-3435-445 4 5

EducationIlliterate1-6 grades7-12 grades

Marital statusMarriedOthers

OccupationHousewifeFarmerUnemployedDaily labourOthersPositiveNegative

Maternal mental distress

Total

15340744040090724824582357786617683

153122335

10651400

46859477

2035247

1311711774417382699

203302

2 031 241 2 81001211 1 21001002 221001 3 01 0 01 2 91 0 51 7 8100

1 30-3.16)(0 87-1.78)(0 98-1.82)

(0.84-1 76)(0.70-1 78)

1 70-2.91)

(0.87-1 93)(0.55-1 80)(0.84-1 96)(0.65-1.71)1 34-2.35)

1 7 81 201 2 31001 0 51 1 01001001 981001201 1 01211 031 7 4100

1 06-2 65)(0 49-1 52)(0 53-1 80)

(0 79-1 56)(0 60-1 60)

1 50-2 01)

(0 80-1 83)(0 44-1 50)(0 74-1 20 )(0 50-1 65)1 30-2 32)

Reference group

The positive association of childhood beha-vioural disorders and maternal age under 25 yearscould be due to teenage parenting, the higherchance for complications during pregnancy andbirth, the higher chance that a child may beunwanted, and poor upbringing. The relation ofchildren's behavioural disorders to single parentingcould be due to more stressful family environmentsin which children must cope with greater externaldemands, because mothers lack support due to theabsence of fathers (4, 6).The significant association between parentalmental distress and childhood behavioural disor-ders could be due to reporting differences betweenparents with mental distress and those without. Thisis because both the diagnosis of mental distress inthe parents and behavioural disorders in theirchildren are based on reports made by parents.Another possible explanation for the positiveassociation between parental mental distress andchildhood behavioural disorders could be thedifferential recall between mothers with mentallyill children and those without mentally ill children.It is possible that mothers of children withbehavioural disorders recall their children's pastillnesses or disturbed behaviours better thanmothers whose children are not mentally ill.The household environment, including the qual-ity of parenting, may also be a risk factor, thusaccounting for the association. The associationcould also be due to factors related to geneticpredisposition of children of mothers with mental

distress to behavioural disorders (4). These factors,working either singly or in combination, canaccount for our observations.Our prevalence estimate of 17.7% for behaviouraldisorders in children indicates that behaviouraldisorders in children are common in this popula-tion. It also indicates the need to initiate mentalhealth services for children in rural communities.AcknowledgementsThe research was conducted as a partial requirement for theDegree of Master of Public Health by Dr. Belayneh Tadesse atAddis Ababa University.Financial and material support for the study was obtained fromthe International Development Research Centre of Canada(IDRC) and the Department of Community Health (DCH).We thank Professor R. Giel for his advice. All interviewersand supervisors, Ato Tewodros Tamru, Ato Moges Mamo, andAto Mekonnen Tadesse are also acknowledged for their hardwork in field supervision, and, especially, our deepest thanks goto Ato Tewodros. The Western Showa Zonal Council is alsoacknowledged for its facilitation of the work in spite of difficultcircumstances in the Ambo woreda during the data collectionperiod. We are grateful to Ato Solomon Berhanu and AtoWondwossen Bekele for the data entry and data cleaning.Caretakers of children who have responded to our interviewsare also gratefully acknowledged.References

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Prevalence estimatesBURROWSD, eds. Handbook of social psychiatry.Amsterdam: Elsevier, 1988: 233-244.3. NIKAPOTAD. Child psychiatry in developing countries.Br J Psychiatry 1991: 158: 743-751.4. WHO. Child mental health and psychological develop-ment. Report of World Health Organization Expertcommittee. Tech. Rep. Series 613. Geneva: WHO, 1977.5. DIOP B, COLLIGNON, GUEYEM, HARDINGW.Diagnosis and symptoms of mental disorder in a ruralSenegal. Afr J Med Sci 1982: 11: 95--103.6. KANGETHE, DHAPHALE. Prevalence of psychiatricillness among Kenyan children. East Afr Med J 1991:68: 526530.7. GIELR, DEARANGOV , CLIMENTE, et al. Childhoodmental disorder in primary health care: result ofobservation in four developing countries. A report fromthe WHO collaborative study on strategies for extendingmental health care. Pediatrics 1981: 68: 677-683.8. GIEL , V A N LUIJKN , BISHAW . Behavioural disordersin Ethiopian children. Psychatr Neurol Neurochir 1969:71: 395400.9. MULATU. The prevalence and risk factors of psycho-

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childhood behavior disorders in ambo ii

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