Actu Psyhiutr Scund 1999. 100.

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Childhood behavioural disorders in Arnbo district, western Ethiopia. I. Prevalence estimates

Tadesse B, Kebede D, Tegegne T, Alem A. Childhood behavioural disorders in Ambo district, western Ethiopia. I. Prevalence estimates. )Munksgaard 1999 Acta Psychiatrica Scand 1999: 100: 92-97. 6 The study was conducted between September 1994 and May 1995 in Ambo district, western Ethiopia. The prevalence of childhood behavioural disorder in children was found to be 17.7%. Behavioural disorder was found to be more common in boys than in girls. The prevalence increased with age. The most frequent symptoms reported were headache and nervousness. The least prevalent symptom was stealing things from home. As age increased, the risk of behavioural disorder increased. The increase in risk was statistically significant in the 15-year-old group when compared to the age group 5-7 years (adjusted Odds Ratio, O R = 1.89, 95% confidence interval, CI: 1.08-2.85). Childhood mental disorder was statistically significantly associated with parental age and with parental marital status. Children whose parents were 5 2 4 years old had a higher risk of having mental disorders (OR: 2.03, 95%CI: 1.30-3.16) compared to those children whose parents were in the 45+ age group. Children whose parents were categorized as unmarried, divorced, separated, or widowed had a higher risk of having behavioural disorders (OR: 2.22, 95% CI: 1.70-2.91) than children whose parents were married. There was a statistically significant association between parental psychoneurosis and children's behavioural disorders; children whose mothers had psychoneuroses were at a higher risk of having behavioural disorders as compared to those whose mothers had no psychoneurosis (OR: 1.78,

B. Tadesse', D. Kebede', T. Tegegne3, A. Alem3

'Oromia Health Bureau, Addis Ababa. 'Department of Community Health, Faculty of Medicine, University of Addis Ababa, and 3Amanuel Psychiatric Hospital, Addis Ababa, Ethiopia

Key words. childhood mental disorders; arevalence; Ethiopia Belayneh Tadesse, Oramia Health Bureau, O.0. Box 22174, Addis Ababa, Ethiopia

Introduction

Childhood mental health programmes are not given sufficient attention in most African countries. This neglect can be attributed, among other things, to the limited information about the extent of childhood behavioural disorders, the inadequate orientation of health workers to mental health problems, and the resulting indifference or negative attitudes toward these problems (1). Although the information on childhood behavioural disorders in developing countries is very sparse, there is evidence that the rate of behavioural disorders in children seen in primary care facilities may, in fact, be similar to the rates in developed countries (2, 3 ) . Surveys of general populations show that the prevalence of persistent and socially handicapping

mental health problems among children aged 3-15 years in developed countries is about 5-1 59'0. More limited data from developing countries suggest a roughly similar rate ( 4 ) .In Africa, a study using the Reporting Questionnaire for Children (RQC) reported that 17% of 545 children aged 5 to 15 years who attended primary health care services in rural Senegal were suffering from some form of emotional problem, behavioural disturbance, or neuropsychiatric disorder (5). In Kenya, Kangethe and Dhadphle (6) screened 303 children aged 5-15 years using the R Q C and found that 20% of the children had clinically significant and definable psychiatric disorders. A WHO collaborative team did a study to measure the frequency of behavioural disorders in 925 children attending a primary health care service in four developing countries. They used the

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Prevalence estimates

RQC with a cut-off point 0/1. They determined the prevalence rates of behavioural disorders to be 12% in Sudan, 15% in the Philippines, and 29% in Colombia (7). In Ethiopia, very few community-based studies have been done to estimate the prevalence of mental illnesses in children. In 1968 Giel et al. (8) studied 381 children aged 0-20 years using psychiatric interviews and found a prevalence of 5.2%. In 1989 another survey utilizing the RQC and the CBPQ (Childhood Behavioural and Psychological Questionnaire) interviewed 860 children aged 3-12 years and found rates of 21.4% for boys and 25.2% for girls (9). We report here on the results of a communitybased survey of childhood behavioural disorders using the RQC in a rural population of western Ethiopia.

Material and methods

The study was conducted between September 1994 and May 1995 in Ambo district, western Ethiopia. Ambo district is one of the 23 districts of the Western Showa administrative zone. The district is located about 120 km to the west of Addis Ababa, the capital of Ethiopia. Ambo district has 136 subdistricts, of which eight are urban sub-districts and the rest are peasant associations. The population of the district is estimated to be 198461, of which 17.3% live in the urban area and 82.7% live in rural areas. The male-to-female ratio in the district is 86: 100. About 13% of the population are 5-1 5 years old. Ninety percent of the population speak Amharic, and about 98% are Orthodox Christians. Approximately 95% of the population are from the Oromo ethnic group. There is one psychiatric nurse working in the district hospital (10). The instrument used to estimate the prevalence of mental disorder in children was the Reporting Questionnaire for Children (RQC) developed by a WHO expert committee on mental health for developing countries. The English version of the RQC was translated into the Amharic language by three psychiatrists independently. Back-translation into English was done by another psychiatrist who did not know the original version. An Amharic version of the Self Reporting Questionnaire (SRQ) was used for collecting data on mental distress in caretakers of the children enrolled in the study. The SRQ has been validated and used in several studies in urban and rural Ethiopia (1 1, 12). We employed interviewers who had completed 12th grade and who spoke Oromifa (the local language) and Amharic (the national language).

Fifteen male and 15 female interviewers were recruited. Two male supervisors were recruited for supervising the interviewers. Supervisors and interviewers were trained for three days. To pretest the questionnaire, 10 randomly chosen parents or caretakers were interviewed from one of the subdistricts in a district not chosen for the main study. From each household, parents or caretakers were interviewed. In cases where both father and mother lived together, the RQC was used to interview mothers about their children, and the SRQ was used to ask them questions about themselves. In cases of refusal to be interviewed or when a child was not available in the sampled household, the next household was chosen. Household numbers were in the order of +1, -1, +2 or -2 of the original house number chosen. Sampling procedure. The source of the study population was all children aged between 5 and 15 years, living in the accessible sub-districts. The sampling units were the households in the district. A sample size large enough to detect the prevalence of mental illness in children was calculated on the basis of prevalence estimates for behavioural disorders in developing countries. The information about the population in rural and urban sub-districts was obtained from district municipality and agriculture departments. The rural sub-districts were stratified in terms of accessibility with regard to transportation. Thirty clusters (subdistricts) were selected out of the 36 accessible rural and urban sub-districts in proportion to population size. All eight urban sub-districts were included in the study. For household selections, a total number of households in the clusters were divided to get the value N (the sampling interval). Both rural and urban area households from each sub-district were chosen by starting from randomly selected households in the sub-district and continuing with every Nth household until 50 households were chosen from each cluster. It was possible to obtain interviews from 1440 households and the response rate was 96%). From these households, 3001 children and 1400 mothers or caretakers participated in the study. Exclusion criteria for households were: 1. There was no child between 5 and 15 years old in the household. 2. Refusal to participate. 3. Caretakers were not available for interview during two visits. In each of these cases, replacements were made as stated above. After the respondents were identified, the interviewers first read out a note to inform them of the purpose of the study, the type of interview, and how it was to be conducted, and the potential benefits for the respondents and their children. Then consent was solicited. After obtaining consent, the inter-

93

Tadesse et al.

viewers read aloud each question. If informants expressed any doubt when deciding a yes or no answer, the interviewer repeated the question without any form of further explanation. Childhood behavioural disorder was defined as a child who scored at least 1 item from the 10 items in the RQC. This cut-off level was determined from a validation study of the RQC reported elsewhere (1 3). Parental mental distress was defined as a parent scoring at least 8 yes answers out of the 20 neurotic symptoms or at least 1 yes answer out of the 4 psychosis symptoms in the SRQ. This cut-off level on the SRQ was determined based on examination of studies that have employed the instrument in surveys in urban and rural Ethiopia (14, 15). Data were entered and analysed using EPI-INFO version 5.0 program and multivariate analysis was conducted using Statistical Analytic System (SAS) version 6.03 program. To evaluate the association of several potential risk factors with mental illness in children, odds ratios (OR) and 95% confidence intervals (CI) were estimated. To adjust for confounding, a logistic regression model was employed. Test for trend was calculated by including the adjusted odds ratio as a continuous variable in a logistic regression model. Test of statistical significance was put at 0.05 level.
Results

A total of 1400 households and 1400 mothers or caretakers was included in the study, and all the mothers responded about the mental status of a
Total with dlsorder
Sex of child Male Female

M ]

1 1 i4 I

of child 5-7 0-10 I 1 14 15+

RQC symptoms responded to: Abnormal speech Sleeping poorly Fits or falling Frequent headaches Stealing things from home Nervousness Backwardness Not playing with others Wetting or soiling oneself

i
4.1

0
Fig. I . Socio-demographic symptoms.

10 15 Percent

1
20
and

25

characteristics

RQC

total of 3001 children. Of these, 49.4% were male. Sixty percent of the mothers were 35 years of age or above, 29% were between 25 and 34, and 11Yn were under 25 years of age. Only 1.6% of the mothers were unmarried. Among the children, 52.5% had completed 1-6 grades, and 9.8% had completed 7-9 grades. Among parents, 58% were illiterate, 19% had completed 1-6 grades, and 23% had completed 7-9 grades. Over 45% of the households had an average family size of 5-7, and 26.3% had an average family size of 2-4. Parents (90.1YO) had an income less than 100 birr (approx. US$ 20) per month. Thirty-nine percent were housewives, 20% were farmers, 14.3% were daily labourers, and 9.5% were skilled workers. The majority (79.5%) were from the Oromo ethnic group; 16.9% were from the Amhara ethnic group. Orthodox Christians constituted 92%)of the households and Moslems 2%. Of the children, 17.7% had at least 1 of the 10 symptoms described by the RQC. Behavioural disorders were found to be more common in boys than in girls. The prevalence increased with age. The most frequent symptoms reported were headache and nervousness. The least prevalent symptom was stealing things from home (Fig. 1). T o evaluate the role of potential risk factors for childhood behavioural disorders, 302 (2 I .6%) households with at least one child with behavioural disorder were compared with the rest of the 1098 households that did not have any child with a behavioural disorder. Although, in the crude analysis, boys appeared to have a higher risk of having behavioural disorders than girls, the association was not statistically significant and decreased further when other variables were adjusted for in a multivariate model (Table 1). As age increased, the risk of behavioural disorder increased. The increased risk was statistically significant in the 15-year-old group when compared to the age group 5-7 years. Adjustment for potential confounding variables gave similar results, as shown in Table 2. Children who had some formal school education were at slightly higher risk for behavioural disorders than children who had no formal education, but this difference was not statistically significant. Birth order was not associated with behavioural disorders. There was no significant association between child behavioural disorders and parental income, family size, education, occupational status, ethnicity, or religion. Childhood behavioural disorders were associated with both parental age and marital status. Children whose parents were 24 years of age or younger were

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Prevalence estimates
Table 1 Demographic correlates of childhood behavioural disorders among children 5 to 15 years of age in Ambo district, western Ethiopia. 1995 Odds ratio crude Odds ratio Adjusted

Characteristics

Population

Cases

(95% CI)

(95% Cl)

Sex Male Female

Age

691 709 41 0 41 8 480 92 528 734 138 644 508 248 1400

160 142 79 85 108 30 115 152 35 144 103 55 302

120 100" 100" 170 1.22 2 04

1 .oo* 0 94 1 22

(0 92-1.57)

112 100" 100"

(0 80-1 40)

5-7 8-1 0 11-14 15

Education Illiterate 1-6 grades 7-1 2 grades Birth order

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

1 02

(0 62-1 30)

115 189 100" 0 87 130 100" 105 108

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

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

(0 70-1 301 (0 70-2 01)

1St

2-4
25 Total
* Reference group

1 .oo* 0 88 0 98

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

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

at a higher risk of having behavioural disorders than children whose parents were in the 45+ age group. Children whose parents were categorized as unmarried, divorced, separated, or widowed had a higher risk of having behavioural disorders than children whose parents were married. The odds ratios of behavioural disorders with parental age and marital status did not alter appreciably when potential confounders were controlled for in a multivariate model (Table 2). The prevalence of mental distress in the mothers Twenty-two percent of the mothers had was 23.9%~ probable neurosis and 4.7% had probable psychosis. There was a statistically significant association between parents' report of mental distress and their children's behavioural disorders. Children whose mothers had mental distress were at a significantly higher risk of having behavioural disorders than children whose mothers had no mental distress. This association persisted even when potential confounding variables were adjusted for (adjusted OR: 1.74, 95Yn CI: 1.30-2.32). N o statistically significant association was found between mental distress in the fathers and children's behavioural disorder.
Discussion

We have shown that a large proportion of the children in this study have behavioural disorders. We have followed several procedures to ensure that the results are valid. In order to minimize the introduction of possible bias during data collection, data collection was carried out by persons who were not health care professionals and who were given appropriate training. The sample size was large

enough. In all households, mothers were designated as the respondents who provide information about their children's behavioural status so that there was a consistency among respondents, at least by sex pattern. Because the items were unambiguous and described recognizable behavioural and developmental problems, it was not necessary that a parent be literate to respond. In order to minimize the possibility of selection bias, all children in a household who were between 5 and 15 years old were included in the study. Multivariate logistic analysis was also employed to adjust for potential confounders. The prevalence of behavioural disorders found in this study approximates those from other studies that have employed the same instrument. Community surveys in developed countries have found prevalence ranging from 3% to 15Yn (4). In a study that used a cut-off point of 2 or more items in rural Senegal, prevalence was 16.9'31( 5 ) . Using the same instrument and a cut-off point of 1 or more items, Giel et al. reported a prevalence of 12% in Sudan, 15% in Philippines, 23'Yn in India, and 29% in Colombia (7). In Kenya, the prevalence was 30% (6). The higher prevalence (24%1) found in Ethiopia by Mulatu (9) than the 17.7% we found in our study could be due to differences in the age groups studied, the use of different methodologies, the differing proportion of urban children in the two studies, or due to socio-cultural differences between the communities studied. The association between childhood behavioural disorders and the child's age, the maternal age and single parenthood is also consistent with the results of other studies in developing and developed countries (3, 4, 9).

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Tadesse et al.
Table 2 The distribution of childhood behavioural disorders, according to parental characteristics, among children 5 to 15 years of age in Ambo district. western Ethiopia. 1995 Odds ratio Crude Odds ratio Adjusted

Characteristics Age

Population

Cases

(95% CI)

(95% CI)

124 25-34 35-44 545

Education Illiterate 1-6 grades 7-12 grades Marital status Married Others Occupation Housewife Farmer Unemployed Daily labour Others Maternal mental distress Positive Negative Total * Reference group

153 407 440 400 907 248 245 823 577

46 85 94 77 203 52 47 131 171 177 44 17 38 26 99 203 302

2 03 1 24 128 100" 121 112 100" 100" 2 22 100" 130 100 129 105 178 100"

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

178 1 20 123 100" 105 110 100"

100" 1 98

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

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

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

(1 70-2.91)

(1 50-2 01)

866 176 83 153 122

335 1065 1400

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

(1 34-2.35)

100" 120 110 121 1 03 174 100"

(0 80-1 (0 44-1 (0 74-1 (0 50-1

83) 50) 20) 65)

(1 30-2 32)

The positive association of childhood behavioural disorders and maternal age under 25 years could be due to teenage parenting, the higher chance for complications during pregnancy and birth, the higher chance that a child may be unwanted, and poor upbringing. The relation of children's behavioural disorders to single parenting could be due to more stressful family environments in which children must cope with greater external demands, because mothers lack support due to the absence of fathers (4, 6). The significant association between parental mental distress and childhood behavioural disorders could be due to reporting differences between parents with mental distress and those without. This is because both the diagnosis of mental distress in the parents and behavioural disorders in their children are based on reports made by parents. Another possible explanation for the positive association between parental mental distress and childhood behavioural disorders could be the differential recall between mothers with mentally ill children and those without mentally ill children. It is possible that mothers of children with behavioural disorders recall their children's past illnesses or disturbed behaviours better than mothers whose children are not mentally ill. The household environment, including the quality of parenting, may also be a risk factor, thus accounting for the association. The association could also be due to factors related to genetic predisposition of children of mothers with mental
96

distress to behavioural disorders (4). These factors, working either singly or in combination, can account for our observations. Our prevalence estimate of 17.7% for behavioural disorders in children indicates that behavioural disorders in children are common in this population. It also indicates the need to initiate mental health services for children in rural communities.
Acknowledgements
The research was conducted as a partial requirement for the Degree of Master of Public Health by Dr. Belayneh Tadesse at Addis Ababa University. Financial and material support for the study was obtained from the International Development Research Centre of Canada (IDRC) and the Department of Community Health (DCH). We thank Professor R. Giel for his advice. All interviewers and supervisors, Ato Tewodros Tamru, Ato Moges Mamo, and Ato Mekonnen Tadesse are also acknowledged for their hard work in field supervision, and, especially, our deepest thanks go to Ato Tewodros. The Western Showa Zonal Council is also acknowledged for its facilitation of the work in spite of difficult circumstances in the Ambo woreda during the data collection period. We are grateful to Ato Solomon Berhanu and Ato Wondwossen Bekele for the data entry and data cleaning. Caretakers of children who have responded to our interviews are also gratefully acknowledged.

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