Pathways to Child Mental Health Services Among Patients in an Urban Clinical Setting in Egypt

In 2011 Egypt’s population was 82.6 million, and 31% were children under age 15 (1). Recent work in Bahrain, Egypt, Morocco, Saudi Arabia, and Tunisia has indicated that the prevalence of major psychiatric disorders among children and adolescents is similar to that in other parts of the world (2).

Until recently, children’s mental health and psychiatric services for children were not given high priority in Middle East countries. Although services for children and adolescents with psychiatric disorders are still insufficient in Egypt, interest has been growing in improving such services. Outpatient clinics for children and adolescents are available in seven mental health hospitals in Egypt—in Abbasseya, Elkhanka, Helwan, Maamoura, Benha, Assiut, and Port Said. Only 11 beds are available for adolescent male inpatients in Helwan mental health hospital (3). Hospital psychiatric departments at Cairo University (www.medicine.cu.edu.eg/beta) and Ain Shams University (www.asuip.net) have recently established outpatient services for children and adolescents, with very few psychiatric beds.

A 2006 assessment of the mental health system in Egypt indicated that only 5% of primary care physicians, 1% of nurses, and 6% of other primary care workers had received at least two days of refresher training in mental health (4). Less than 20% of physician-based primary care clinics have assessment and treatment protocols for key mental health conditions. Although 97% of schools employ a part-time or full-time health professional, only about 1% of these professionals are trained in mental health. Less than 20% of primary care physicians in physician-based clinics make an average of at least one referral a month to a mental health professional (5).

Children may have a wide range of mental health problems. However, health care providers and the public in Egypt are not as aware of this as they should be, which may delay the diagnosis of these problems, with negative consequences for the child’s functioning and well-being. Because we recognized the lack of practice guidelines for managing children with mental health problems, we believed it was important to study referral patterns for undiagnosed children in an urban governmental mental health service facility. We wanted to explore associations between patients’ characteristics and health service providers’ practices and the duration of illness before a psychiatric consultation was obtained. An important goal of this descriptive research was to guide mental health policy makers to target these referral sources in awareness programs.

Methods

This cross-sectional study was conducted after approval by the Faculty of Medicine Ethical Committee, Ain Shams University, Cairo.

Participants

Over three months (March to May 2011), 150 new pediatric patients presented to the child psychiatry outpatient clinic, which is held five days a week at the Institute of Psychiatry of Ain Shams University hospitals. Of these, 27 patients were excluded—13 because they did not consent to participate and 14 because they had been referred for consultation regarding psychiatric morbidity resulting from a general medical condition. We believed that including the latter patients would bias the results; our study was focused on duration of illness before receipt of a proper diagnosis, and these children were being seen regularly in other specialties, which made early detection of their psychiatric morbidity more likely. A total of 123 patients age two to 15 were enrolled in the study after written informed consent was obtained from parents or legal guardians.

Procedure

The psychiatric history of all children was obtained, and a full psychiatric examination was conducted. Intelligence was assessed with the Arabic version of Stanford-Binet Intelligence Scale (5), by which mental retardation was diagnosed. The Arabic version of the Gilliam Autism Rating Scale (6), which is designed to screen and diagnose autism among individuals age three to 22, was used. The Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime version (7) was used to diagnose other psychiatric disorders. It is a semistructured diagnostic interview designed to assess psychopathology among children and adolescents according to DSM-IV criteria. Although it has been used mostly with school-age children (six to 18 years), a recent study indicated that it may be useful in the screening and diagnosis of preschool-age children via parent interviews and that it may be considered for use in assessing children age two to 18 years, particularly in studies of clinical samples (8).

Fahmy and Sherbini's Social Classification Scale (9) was used to determine the social class of patients. On the basis of both parents’ education, employment, and income and on a crowding and sanitation index, patients were classified as belonging to a high, middle, low, or very low social class. A researcher-designed questionnaire was used to obtain data about family history of a similar condition and about the family’s first contact for consultation and for a second opinion, the source of the referral, the duration of illness before psychiatric consultation, and the most distressing symptom.

Statistical analysis

Data were analyzed with SPSS, version 17 (10). The Pearson chi square test was used to detect significant associations between categorical variables. The independent-sample t test (Student’s t test) was used to compare means of different patient groups. Analysis of variance was used to compare quantitative data between more than two groups. The level of significance was set at p≤.05.

Results

The sample consisted of 73 (59%) males and 50 (41%) females. The mean±SD age was 8.1±3.2 years (range two to 12 years). Sixteen patients (13%) belonged to a high social class, 38 (31%) to a middle social class, and 69 (56%) to a low social class. Diagnoses were as follows: 34 (28%), attention-deficit hyperactivity disorder (ADHD); 30 (24%), mental retardation; 21 (17%), autism; 21 (17%), conduct disorder; and 22 (18%), childhood depression, anxiety, or schizophrenia. A total of 17 children (14%) had nocturnal enuresis.

For 77 children (63%) the most distressing symptom was behavioral problems, followed by delayed language development for 22 children (18%), poor scholastic performance for 16 (13%), and delayed developmental milestones for eight (7%). The mean duration of illness before psychiatric consultation was 3.4±3.1 years. Diagnosis and social class were significantly associated with delayed treatment seeking, whereas gender, most distressing symptom, and positive family history were not (Table 1). Post hoc tests indicated that parents of children with ADHD, conduct disorder, psychosis, depression, and anxiety sought psychiatric consultation sooner than parents of children with autism, mental retardation, and nocturnal enuresis. Also, parents in a high social class sought consultation sooner than those in a middle or low social class.

Parents’ help-seeking pattern

Most parents first contacted either a pediatrician (38%) or a psychiatrist (29%) about their child’s mental health condition (Table 2). A smaller proportion (7%) contacted a general practitioner. Other specialties first contacted included neurology and neurosurgery (7%) and urology (2%). Traditional healers were the first contact in 5% of cases. Many families had sought second opinions about their child’s condition. Sixty-five (53%) had consulted pediatricians, 29 (24%) had consulted speech therapists, and 22 (18%) had consulted traditional healers.

Gender and social class were not significantly associated with help-seeking patterns, whereas diagnosis and most distressing symptom were strongly associated with help-seeking patterns (Table 3).

Referral source

The largest proportion of patients (30%) was referred by relatives (at a mean age of 9.9± 3.2 years), followed by pediatricians (21%) (mean age 8.7± 4.0 years), speech therapists (16%) (mean age 4.9± 2.3 years), and school teachers (12%) (mean age 7.8±2.0 years) (Table 2). Only a small proportion of patients (7%) were referred by neurologists or neurosurgeons. Media and traditional healers had a minor role in referral (5% each).

Gender and social class were not significantly associated with referral source, whereas diagnosis and most distressing symptom had strong associations with referral source (Tables 4 and 5).

Discussion

The study sample included 123 new patients who visited a child psychiatry outpatient clinic at Ain Shams University hospitals over three months. On average, 45 new patients visit the clinic each month. Because these tertiary care hospitals serve a large catchment area of Greater Cairo, patients with a wide variety of diagnoses were included in the sample. Twenty-eight percent had ADHD, 17% had conduct disorder, and 14% had nocturnal enuresis. These rates are higher than those in a study in Norway, which found that referrals for hyperactivity and attention problems were 14% in 2001 (11). Only 10% of a sample in Western Australia had a diagnosis of a conduct disorder, whereas 17% had mixed disorders of conduct and emotion, and 42% had emotional disorders (12). In our study, 18% of the sample met criteria for childhood anxiety, depression, or schizophrenia, compared with 42% in the Australian study. It may be that families in Egypt are more disturbed by externalizing behaviors than by internalizing behaviors, which are disturbing to the child and may be overlooked by the family. Alternatively, the prevalence of childhood depressive disorders may be lower in Egypt than in other countries because of stronger family cohesion, which is a known protective factor.

Our results are comparable to those found in developed countries ten years ago, which may reflect the gap between the needs of children in Egypt and the mental health services that are currently available. A New York study published in 1999 found that disruptive behavior disorder was significantly associated with children's use of mental health services, but depressive disorder was not (13). In that study, parents of children with disruptive behavior disorder perceived a greater need for mental health services than parents of children with depression. Seventeen percent of our sample had an autism disorder, and 24% had mental retardation. It may be that local multidisciplinary teams lack a child psychiatrist to manage such cases, which leads parents to seek consultation on an individual basis at child psychiatry departments.

The mean age of children in our sample was 8.1 years, and the mean duration of illness before psychiatric consultation was 3.4 years. The findings may indicate that families tended to tolerate the child’s psychiatric problem as long as it was confined within the family. Or the findings may reflect a long denial process that extended until the child faced external challenges at school. Stigma associated with mental illness and misconceptions about psychotropic medications are also potential explanations. Our results are similar to those of a study in the United Arab Emirates in which the main reasons for not seeking consultation were reluctance to acknowledge that a family member has a mental illness and stigma and the skepticism about the usefulness of mental health services (14). In that study, willingness to use psychiatric services was associated with better parental education, occupation, and socioeconomic status. In a study in Iran, the most common barriers to service use were logistic, particularly service cost and inconvenient access (15). Barriers related to perceptions of mental health services were also noted, such as a lack of trust and concerns about the perceptions of friends and family.

In our sample, 63% of parents reported that behavioral problems were the most distressing symptom. This finding emphasizes the fact that regardless of the nature of a child’s mental disorder, it is the child’s disturbing behavior that pushes the family to seek treatment. Delayed language development was the most distressing complaint for 18% of the children, mostly girls, which may reflect a cultural belief that boys naturally lag behind girls in language development. Compared with behavioral problems, poor scholastic performance was a minor concern, with only 13% of parents reporting it as the most distressing complaint. This finding may reflect the low socioeconomic status of our sample; 56% belonged to a low social class. Poor households are less likely to enroll their children in school than households in the top 20% of income distribution (16).

In our study, the nature of most distressing symptom was not significantly related to the duration of illness before psychiatric consultation. However, duration of illness before consultation was significantly shorter for children with diagnoses of ADHD, conduct disorder, psychosis, and mood and anxiety disorders and for children in a high social class. Previous research on ADHD has found a delay of about 1.5 years from the time that parents suspect that their child has ADHD and the first referral (17). That study found that the most common reason for the delay was lack of knowledge about where or from whom to seek help. In most cases, teachers were the first to suggest a diagnosis of ADHD.

We found that behavioral problems were significantly associated with referrals to pediatricians, followed by referrals to speech therapists. In addition, behavioral problems were significantly associated with referral by relatives, followed by referrals by pediatricians. Previous research found that parents’ level of distress, a family psychiatric history, and discussion of concerns with a pediatrician were important factors in the identification of a psychiatric problem by a pediatrician and referral by the pediatrician to a mental health specialist for further evaluation and treatment (18).

In our study, a substantial proportion of patients with ADHD were referred by school teachers (24%), and a good percentage were referred by media (14%). This finding is comparable to that of a previous study in which radio and television were the main source of knowledge about ADHD and in which teachers were the first to suggest the diagnosis of ADHD in most cases (17).

In our study, most patients with autism and mental retardation were first seen by pediatricians and were referred by speech therapists, followed by pediatricians. Most patients with nocturnal enuresis were first seen by pediatricians and were referred by relatives, as were patients with anxiety and mood disorders and schizophrenia. These findings may indicate a lack of awareness among pediatricians and teachers, many of whom are not trained in early detection of mental disorders among children, although they are the professionals who have most contact with children. Our results are in accord with those of a previous study that found that parents and teachers were more likely than health care professionals to be the first to identify children with a probable psychiatric disorder (18).

Researchers have concluded that misconceptions about mental disorders are widespread in the Middle East, not only among laypersons but also among health professionals (17,19). For example, it is commonly believed that mental disorders are not real disorders. In developing countries, mental disorders are considered to be rare or largely untreatable, and many believe that a child’s psychiatric disorder is a sign of the child’s independence from his or her parents rather than a mental illness per se. A previous study found that most primary care pediatricians and child and adolescent psychiatrists in developing countries agreed that pediatricians should be responsible for identifying and referring children with mental disorders, except for ADHD, but not for treating children’s mental health conditions (20). Primary care pediatricians in that study were more likely than child and adolescent psychiatrists to agree that pediatricians should identify and treat children with ADHD. Both groups agreed that lack of mental health services was a barrier for identification, treatment, and referral of children with mental health problems by primary care pediatricians. Child and adolescent psychiatrists were more likely to agree that pediatricians' lack of training in identifying child mental health problems was a barrier.

In our study, traditional healers had been consulted in 18% of cases. In in the Middle East, traditional religious healers (sheikhs) have a major role in primary mental health care (21,22). Patients, especially those in rural areas, often go to traditional and religious healers before or after seeking medical advice from health professionals. This trend is difficult to study, especially when patients use both the health system and traditional approaches (4).

A limitation of our study was that it was conducted at a single clinic rather than at multiple facilities across the country, thus limiting the generalizability of the results.

Conclusions

We found that behavioral symptoms were the main reason for seeking psychiatric services in a pediatric population in Egypt and that delayed psychiatric consultation was primarily related to belonging to a middle or low social class. Most parents first sought advice from pediatricians, and a substantial number consulted traditional healers. Awareness programs that target pediatricians and elementary school teachers are urgently needed to shorten the duration of undiagnosed illness among children. Psychiatrists and traditional healers should find a way to collaborate in helping children with psychiatric disorders.