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Child psychiatric morbidity in community samples is estimated at about 10% to 20%; however, the estimates of the prevalence largely depend on the choice of concepts and instruments, as well as on the nosology and classification (1). A review of 52 studies conducted over the past 4 decades revealed a mean prevalence rate of 15.8% (range 1% to 51%) (2). These authors also observed that the rates varied, depending on the age, with moderate rates of 8% for preschoolers and 12% in studies including wider age ranges. A recent study of mental disorders among children in the UK reported that about 10% of children aged 5 to 15 years have some type of mental disorder (3). These rates were based on ICD-10 classification of mental and behavioural disorders with strict impairment criteria. A review of international studies found that the average prevalence figure for clinically significant disorders in 6 DSM-III or DSM-III-R–based studies was 14.3% (4). The prevalence rates were also influenced by the source of the sample (for example, whether the children were from the community, from schools, or from primary care settings). Rates in the primary care setting have been higher, ranging from 15% to 40% (5). Systematic studies of children with psychiatric disorders using present-day epidemiologic tools, including clinical interview, have been lacking in the developing countries, including those in the Arab region. Earlier studies from the United Arab Emirates (UAE) have included school population and primary care samples (6). Although school or primary care–based studies are easier to conduct, these may not accurately reflect the nature and prevalence of psychiatric disorders as they occur in the community. This is because children with psychiatric disorders attend the primary care facility more often than those who do not suffer from psychiatric disorders, thus yielding a higher prevalence (7). In fact, school-based studies may miss children in the community who do not attend school. This is particularly relevant, because psychiatric disorders may be overrepresented among school dropouts. The present study was carried out to ascertain the nature and prevalence of DSM-IV child psychiatric disorders in a representative random sample of UAE national households in the community in Al Ain District. The study also examined the association, if any, between psychiatric disorders and relevant individual, family, and psychosocial variables. We studied the UAE national population only, with the hope that this would reduce the effects of sociocultural and economic factors, as well as the influence of migration on the morbidity rates. Material and MethodsAl Ain’s population is estimated at about 308 000 (Annual Report 1996, Preventive Medicine Department, Ministry of Health, UAE), of which one-third are UAE citizens (that is, 99 417 nationals, with 48 032 males and 51 385 females). The remaining population consists of expatriates from about 40 countries who have come to work in this Gulf area on short-term employment contracts. In this study, to minimize the effects of migration and other sociocultural characteristics that influence psychiatric morbidity, we included only UAE national citizens. A population list for Al Ain was unavailable; subsequently, we employed a systematic sampling method. To identify the households for sampling, detailed maps of the Al Ain district were obtained from the city council. The households were selected according to the random-walk technique of Cochrane and Stopes-Roe (8). First, a random selection of streets was made, and from each selected street, the first house was chosen, followed by every other house on the same side of the street. If this was an apartment with multiple units, the first apartment was chosen for the study. If the selected household was not occupied by UAE citizens, the next house was taken in sequence. All the chosen households were served a notice 1 or 2 days prior to the interview, with a letter explaining the purpose of the survey. The local research ethics committee approved the study, and informed consent was obtained from the parent or guardian. In each selected household, 1 child ranging in age from 6 to 18 years was identified using the lot method (that is, from the names of all the children in the household, 1 name was drawn). The study was carried out in 2 stages. Stage 1 included identifying the eligible households (that is, households with children aged 6 to 18 years, unless they were too ill or cognitively impaired) and screening using the Rutter Parent Questionnaire. The first-stage survey was carried out in 620 children by trained nurses with previous survey experience, along with the Al Ain adult community study (9,10). A random sample of 385 households was preselected for the second stage, regardless of screening scores on the Rutter scale. A smaller second-stage sample was taken because of financial and technical constraints in carrying out detailed psychiatric interviews in a larger sample. In this paper, we provide the results of the Stage 2 study. Second-stage interviews were conducted using the Kiddie Schedule for Affective Disorders and Schizophrenia for school age children (K-SADS) (11), a semistructured diagnostic interview covering all the major DSM-1V diagnoses. The K-SADS is administered by interviewing the parent first and then, depending on the age, interviewing the child with or without the parent present. All interviews were carried out privately in the households by 2 trainees in psychiatry who were already trained in K-SADS as part of a previous study. In this study, the child as well as the mother (or a guardian who knows the child well) was interviewed, and a summary rating was made to allow a best-estimate diagnosis using DSM-IV (12). The children who were judged as having a psychiatric disorder were rated using the Children’s Global Assessment Scale (CGAS) (13), as classified in Axis Vof the DSM-IV, to determine the degree of dysfunction. Scores below 70 were considered mild, scores between 51 and 60 were considered moderate, and scores below 50 were considered severe. Using a semistructured questionnaire, we obtained socio- demographic information, including details about family composition (nuclear, extended, or reconstituted), separation or loss of parent, income, parental education (total years in education from 0 to 12 years) and occupation, polygamy (that is, father having more than 1 wife) and consanguinity, family history of psychiatric disorders, and problems with the use of alcohol or drugs in a family member. Although it would be reasonable to assume that informants may be reluctant to report on alcohol and drug problems, for moral, religious, and legal reasons, we believe that such reasons for underreporting may not have been relevant when the questions addressed the household rather than any specific individual. Individual factors pertaining to the child, such as birth order, physical health, and scholastic performance, were also ascertained.
ResultsOf all the houses selected for Stage 2 (n = 385), data were completed for 329 children, with a response rate of 86%. The reasons for noncompletion of Stage 2 interviews in the remaining 14% were as follows: incomplete records (7 subjects); unavailability of the identified study subject or a parent for interview, even after 2 visits (26 subjects); families refusing the interview, citing unavailability of time for the parent (17 subjects); and other reasons (6 subjects). There were 165 boys and 164 girls, and the mean (SD) age of the sample was 10.8 (3.3) years, ranging from 6 to 18 years. The mean (SD) number of children in the household was 6.6 (3.1), with a range of 2 to 17. Nearly one-quarter of the families had 4 or fewer children, one-half had 5 to 8 children, and the remaining one-quarter had over 8 children. About 70% of the children were living with both parents in nuclear families. Of the 329 children, 73 (22.2%) were found to have at least 1 DSM-IV diagnosis. Table 1 provides the details of the various psychiatric diagnoses among the 47 children who showed significant functional impairment. Various forms of mood disorders were the most prevalent, present in an estimated 3%, closely followed by anxiety-related disorders. Likewise, 47 (14.3%) of the 329 children had moderate-to-severe impairment in functioning, as indicated by a CGAS score of less than 60. None of the children had received a psychiatric diagnosis prior to the survey. With respect to the rates of individual psychiatric disorders, the issue of comorbidity, which refers to subjects with more than 1 diagnosis, requires consideration. In this study, we found that 45% of subjects (33 children) with psychiatric disorders had more than 1 diagnosis. Discriminant function analysis with DSM-1V case and noncase as the dependent variable showed a statistically significant association with sex, family size, quality of parental marriage, availability of domestic help, chronic life difficulties, family history of psychiatric disorder, and having a relative with alcohol problems (Table 2). Psychiatric disorder was not associated with age, parental education or occupation, family income, polygamy, or family structure. Although there were no significant differences for overall psychiatric morbidity vis-à-vis age, there was a tendency for individual psychiatric disorder, particularly mood disorder, to be higher among adolescent girls. The latter, however, did not reach statistical significance.
DiscussionOf the 329 children, 73 (22.2%) from a nonreferred sample in the community were found to have at least 1 DSM-IV diagnosis, and 47 (14.3%) had a DSM-1V disorder with moderate-to-severe functional impairment. This compares with other DSM-based studies that found prevalence rates of 18.7% in the US (14), 17.9% in Puerto Rico (15), and 22.5% in Switzerland (16). An earlier study from the schools in the UAE found a weighted prevalence rate of 10.4% for DSM-1V disorders (6). As in previous general population and primary care surveys in the UK (17,18), the US (19), Africa (20), and the UAE (6), adverse family factors were found to be associated with psychiatric disorder. In this respect, large family size, chronic life difficulties, and a history of psychiatric disorder or an alcohol problem in a family member are noteworthy. Surprisingly, we failed to find any link with family composition, socio- economic status, parental education and occupation, or parental loss through death or divorce. This may be due to the broad sociocultural similarity in our base population with respect to these variables, making differences between the 2 groups comparatively small and limiting the statistical power of the sample. Other studies from the region have also failed to find any association between psychiatric morbidity and sociodemographic correlates such as education, occupation, and income (21). The association between psychiatric morbidity and family history of mental illness reflects the findings from the literature. This may indicate shared genetic and environmental factors that are complex and that may have an additive effect. Having a close relative with an alcohol problem seems to be a risk factor that is unique to this culture, previously identified in a community-based study of women in the UAE (21) and among women with postpartum psychiatric disorders (22). This may be due to the traditional orthodox attitudes prevalent in the society, which forbid the use of alcohol, thus possibly causing significant stress to the family if a member has problems relating to alcohol use. Our finding of an association between psychiatric morbidity and female sex is interesting. This contrasts with the available evidence from the literature suggesting that a higher preponderance of psychopathology exists among boys (15–17) or that the rates do not significantly differ (14). An earlier study carried out in Al Ain schools also found higher rates among boys (6). It may be that the sex distribution for the occurrence of psychiatric morbidity in our community differs, in which case the reasons for such differences would be complex. There are several factors to be considered in this respect. First, the present study included only UAE citizens, whereas the earlier school study included all Arabic-speaking children who resided in the UAE. Perhaps, the UAE national population differs from other Arab nationalities in this respect. Interestingly, other studies carried out among the adult population in the region have also found a reverse trend in sex distribution. A study from the eastern region of Saudi Arabia reported higher rates among men (23), and another study from the UAE found no statistically significant difference between men and women (24), compared with worldwide literature, suggesting higher morbidity rates among women. Second, UAE national parents may be underreporting behavioural and psychiatric disturbance in boys, owing to a culturally shared higher tolerance threshold for such behaviours. Conversely, mood disorders were found to be higher among older girls. These factors may have influenced the overall reported rates for psychiatric disorder to be higher among girls. When viewed with the UAE school study that used the same instruments but also with access to school and to teacher reports, which found higher rates among boys, this finding may at least in part be influenced by such reporting bias and by the age distribution of the sample. Yet, another finding that deserves further exploration is the relatively low rate of attention-deficit hyperactivity disorder (ADHD), which may be linked to the issue of comorbidity, because a few of these individuals may have received a diagnosis of conduct or oppositional defiant disorder. In fact, the rates described are for those with significant functional impairment, and those with comorbid conditions are more likely to be functionally impaired. Another reason for the low rates may be the higher tolerance threshold for hyperactivity in this culture, coupled by the fact that, in this study, school or teacher reports were unavailable. Some of the study’s limitations need to be acknowledged. Our sample did not include measures to tap organic dysfunction and intellectual level. The issue of comorbidity was not addressed. In individuals who had more than 1 diagnosis applied, only 1 best-estimate diagnosis was assigned. Thus, it is possible that a child who reported having a particular diagnosis may have had other comorbid conditions. In addition, we have used a broad age range of 6 to 18 years, and our sample size was inadequate to determine age- and sex-specific prevalence rates. Further, we obtained information from 1 source only, namely, the parent. A teacher questionnaire was not included. We may have omitted some cases wherein the disturbance was predominantly school-related. Earlier studies, however, have suggested better agreement between parental report and psychiatrist assessment, compared with that of teacher report and psychiatrist assessment (25). Also, parents may have responded negatively to interview items because of social stigma that is attached to mental illness; however, our experience from earlier studies has shown that, when information from parents is combined with that of the clinical interview with the child, a high level of diagnostic sensitivity and specificity can be obtained (26). Notwithstanding these limitations, our findings have important clinical implications with respect to health care planning and to provision in the UAE and the region. This is particularly so because data concerning the prevalence and nature of child psychiatric disorders from the community are sparse in this region. Given the shortage of child mental health professionals, attention to mental health problems in children in primary care would seem highly appropriate. To the best of our knowledge, this is the first epidemiologic study of child psychiatric disorders in this region using present-day instruments, including clinical interview in a sample of nonreferred children in the community. Our prevalence rates of 22.2% for any DSM-1V diagnosis and 14.3% for DSM-IV diagnosis with moderate-to-severe functional impairment are similar to those reported in Western studies. However, none of the individuals identified through the study had received any professional attention for their mental health problem. It seems likely therefore that these children were being denied the treatment option because of the failure in the system to detect and to diagnose psychiatric morbidity. Research evidence indicates that childhood psychiatric disorder has long-term consequences, specifically, with respect to delinquency, crime, and substance abuse. Early recognition and prompt treatment may relieve the psychological and social burden, which will otherwise continue to hamper children’s future functioning. This is particularly important in the planning of social and health services in the UAE—one-third of its population consists of children under age 18 years. It follows that there is a need to raise awareness among parents and to provide appropriate training for community and primary care professionals who come in contact with children and adolescents. Funding and SupportThis study was supported by a grant from the Faculty of Medicine, UAE University, Al Ain, United Arab Emirates. References1. Verhulst FC, Koot HM, editors. The epidemiology of child and adolescent psychopathology. Oxford: Oxford University Press; 1995. 2. Roberts RE, Attkinson CC, Rosenblatt A. Prevalence of psychopathology among children and adolescents. Am J Psychiatry 1998;155:715–25. 3. Office for National Statistics. Mental health of children and adolescents. London (UK): Department of Health; 1999. 4. Bird HR. Epidemiology of childhood disorders in a cross-cultural context. J Child Psychol Psychiatry 1996;37:35–49. 5. Kramer T, Garralda ME. Psychiatric disorders in adolescents in primary care. Br J Psychiatry 1998;173:508–13. 6. Eapen V, Al-Gazali L, Bin-Othman S, Abou-Saleh MT. Mental health problems among school children in United Arab Emirates: prevalence and risk factors. J Am Acad Child Adolesc Psychiatry 1998;37:880–6. 7. Westman A, Garralda ME. Mental health promotion for young adolescents in primary care: a feasibility study. Br J Gen Pract 1996;46:317. 8. Cochrane R, Stopes-Roe M. Factors affecting the distribution of psychological symptoms in urban areas of England. Acta Psychiatr Scand 1980;61:445–60. 9. Eapen V, Swadi H, Sabri S, Abou-Saleh M. The Al Ain Community Psychiatric survey: childhood behavioural disturbance. East Mediterr Health J 2001;7:428–34. 10. Abou-Saleh MT, Ghubash R, Daradkeh TK. Al Ain Community Psychiatric Survey 1. Prevalence and socio-demographic correlates. Soc Psychiatry Psychiatr Epidemiol 2001;36:20–8. 11. Chambers W, Puig-Antich J, Hirsch M, Paez P. The assessment of affective disorders in children and adolescents by semistructured interview. Arch Gen Psychiatry 1985;42:696–702. 12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington (DC): American Psychiatric Association; 1994. 13. Bird HR, Yager TJ, Stagezza B, Gould MS, Canino G, Rubio-Stipec M. Impairment in the epidemiological measurement of childhood psychopathology in the community. J Am Acad Child Adolesc Psychiatry 1990;29:796–803. 14. Kashani JH, Beck NC, Hoeper EW, Fallahi C, Corcoran CM, McAllister JA, and others. Psychiatric disorders in a community sample of adolescents. Am J Psychiatry 1987;144:854–589. 15. Bird HR, Canino G, Rubio-Stipec M, Gould MS, Ribera J, Sesman M, and others. Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. Arch Gen Psychiatry 1988;45:1120–6. 16. Steinhausen HC, Metzke CW, Meier M, Kannenberg R. Prevalence of child and adolescent psychiatric disorders: The Zürich Epidemiological Study. Acta Psychiatr Scand 1998;98:262–71. 17. Rutter M, Cox A, Tupling C, Berger M, Yule W. Attainment and adjustment in two geographical areas, I: the prevalence of psychiatric disorder. Br J Psychiatry 1975;126:493–509. 18. Garralda ME, Bailey D. Children with psychiatric disorders in primary care. J Child Psychol Psychiatry 1986;27:611–24. 19. Costello EJ, Costello AJ, Edelbrook CS, Burns BJ, Dulcan MK, Brent D, and others. Psychiatric disorders in pediatric primary care: prevalence and risk factors. Arch Gen Psychiatry 1988;45:1107–16. 20. Gureje O, Omigbodun O. Children with mental disorders in primary care. Functional status and risk factors. Acta Psychiatr Scand 1995;92:310–4. 21. Ghubash R, Hamdi E, Bebbington P. The Dubai Community Psychiatric Survey I. Prevalence and socio-demographic correlates. Soc Psychiatry Psychiatr Epidemiol 1992;27:53–61. 22. Ghubash R, Abou-Saleh MT. Post-partum psychiatric illness in Arab culture: prevalence and psychosocial correlates. Br J Psychiatry 1997;171:65–8. 23. El-Rufaie OE. A psychiatric clinic in a primary care setting: evaluating the experience. Saudi Med Journal 1988;9:20–4. 24. El-Rufaie OE, Absood GH. Minor psychiatric morbidity in primary health care: prevalence, nature and severity. Int J Soc Psychiatry 1993;39:159–66. 25. Vikan A. Psychiatric epidemiology in a sample of 1510 ten-year-old children I: prevalence. J Child Psychol Psychiatry 1985;26:55–75. 26. Eapen V, Al-Gazali L, Bin-Othman, Abou-Saleh MT. Child psychiatric disorders in the United Arab Emirates: functional status and implications for service provision. Prim Care Psychiatry 1999;5:25–9. Author(s)Manuscript received February 2002 and accepted February 2003. 1. Associate Professor in Child Psychiatry, Faculty of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates. 2. Teaching Assistant, Department of Psychiatry, Faculty of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates. 3. Reader, Department of Addictive Behaviour and Psychological Medicine, St Georges Hospital Medical School, University of London, London, UK. Address for correspondence: Dr V Eapen, Faculty of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates e-mail: veapen@uaeu.ac.ae
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