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

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

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.

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.

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.

The authors report no competing interests.