معرفي انگليسي Introduction

Epidemiology of psychiatric disorders in Iranian children and adolescents across the country and its relationship with social capital, life style and parents' personality disorders

 

Mohammad Reza Mohammadi¹

Nastaran Ahmadi²

Koorosh Kamali³

 

1. Psychiatry and Psychology Research Center, Tehran University of Medical Sciences, Tehran, Iran.

2. Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

3. Zanjan University of Medical Sciences, Zanjan, Iran.

 

BACKGROUND

The latest research shows that almost 20 to 49 percent of children and adolescents suffer some form of psychiatric disorder. There has been a growing need to better understand the prevalence and associated factors for mental health problems in children and adolescents in Iran. The shortage of child mental health services is a priority in the world mental health agenda. Psychiatric community studies are necessary for planning and developing psychiatric services and are helpful in evaluating the socio-demographic correlations of mental disorders in a given community.

 

JUSTIFICATION FOR SUPPORT

Iran recently underwent important social and economic changes. With a population of 78.47 million (50% below the age of 25; and 18 millions between the ages of 7 and 18), a substantial number of children and adolescents might suffer from emotional or behavioural disorders which have substantial implications for health services. 

Child psychiatry in Iran is only beginning - and existing studies are often too simple in their methods to yield the information that is needed.  Such countries do, nevertheless, have particularly strong concerns about child mental health and strong needs for epidemiological surveys.  Rapid sociocultural, political and economical changes may affect the life-styles of communities and families, and influence the physical and psychological well-being of children. A recent review of studies examining rates of behavioural and emotional disorders in children living in Iran suggests that children living in big cities in the country have rates of problems (20% to 40%) as high as, or higher than those living in developed countries. Results showed that there are too many things they need to know about the mental health of children and adolescents. But, we require more valid and detailed information about their mental health to inform our youth health policy and programmes.

 

EXPECTED OUTPUTS

This epidemiological survey will provide the first estimates for the prevalence of specific child psychiatric disorders in a large, representative community sample of Iranian youth. These data will be compared to estimates from other countries and will provide a baseline against which further future estimates could be compared to detect time trends. The survey will allow for an estimation of service needs when planning of services is under way. Variations within the country of rates and patterns of behavioural deviance will give possible clues on risk factors for different subcultures within Iran and will guide services planning more precisely. Survey data for Iranian children will be compared with those from other countries (both developed or not) surveyed with the same methodology. The health professionals working with children in Iran will have access to a large database on normative behaviours and emotions of a large representative group of children and adolescents, this knowledge being necessary to calibrate assessments and interventions in clinical settings and to facilitate research.

The objectives of this study are to conduct with the following specific aims:

·              To assess  the prevalence of child psychological disorders in Iran;

·               To develop appropriate methods for psychological assessment of children and adolescents in Iran;

·              To determine the association of family and demographic variables with psychological disorders;

To assess the needs for child mental health services for Iran.

 

MATERIALS AND METHODS

Study Design

This research, Iranian Child and Adolescent Psychiatric disorders (IRCAP), is a national project that was implemented in all provinces of Iran and was granted by national institute for medical research development (NIMAD).This study is an analytical cross-sectional study.

The principal applicant has conducted large scale surveys of psychiatric disorders and has particular expertise in the use of instruments included in this proposal. Preliminary work has been undertaken during the 4 years ago. Firstly, translations of the screening questionnaires into Farsi have been produced, piloted with families, back-translated in English by professional translators. This procedure has been repeated several times before final versions could be obtained. Secondly, a pilot epidemiological investigation on a large (N=2000) sample of Iranian children is being conducted in Teheran schools by the principal investigator, providing the applicants with the experience of setting up such investigations. Thirdly, an epidemiological investigation has been undertaken by the principal investigator, as investigate the epidemiology of psychological problems in adolescents in five provinces of Tehran, Khorasan Razavi, Isfahan, East Azerbaijan and Fars at 5171 adolescents aged 6 to 17 years. Fourthly, the principal investigator and colleagues have reported the test-retest reliability and the inter-rater reliability of Persian version of K-SADS, in which the sensitivity specificity of Persian version is shown to be high. The main format of this protocol is adapted from Yazd Health Study Protocol.

Sampling

In a community-based study, we selected 1000 children and adolescents aged 6-18 years in each province by multistage cluster sampling method (cluster and stratified random sampling). We randomly collected 170 blocks. Then, of each cluster head, we selected 6 cases, including 3 cases of each gender in different age groups (6 to 9 years, 10 to 14 years, and 15 to 18 years). The blocks were selected randomly according to postal.

Inclusion and Exclusion Criteria

Inclusion criteria were as follows: Being an Iranian citizen (in each province people who reside at least one year in that province could participate in the project) and having an age range of 6 to18 years. Child and adolescents with mental retardation and severe physical illness were excluded.

Data Collection

The clinical psychologists instructed to complete the Persian version of Kiddie-Sads-Present and Lifetime Version (K-SADS-PL). The trained psychologists referred to the children's home and will interview them using the K-SADS-PL. The time required to complete the K-SADS was about 30 to 40 minutes. In addition, demographic data (gender, age, education, parent education and economic situation), information about their lifestyle, social capital and their parents' personality disorders were obtained.

Procedures

1. The site

Iran is the 16th largest country in the world, and has a total population of 78.47 Million inhabitants (71.2% in urban areas, and 28.8% in rural areas); 85% of the population over the age 6 is literate and unemployment rate is around 11% amongst adults. The population is ethnically diverse with large groups from Turkish, Kurdish, Lorish, Baluchi and Arabic origins. The religion is Muslim (98.8%) and the official language is Farsi (the only language used for writing in administrations and the main language used for teaching in schools). Iran has 31 provinces. There are about 104,114 schools (primary and secondary) providing education to 16 million pupils aged 7 to 18.

2. Selection of study areas

The IRCAP survey conducted in 31 provinces of Iran, including the capital.  This provide an opportunity to compare, within Iran, provinces which differ for background characteristics such as ethnicity mix, culture, and economic wealth, allowing detecting fine-tuned variations in rates of individual behavioural and emotional problems in children which might call for differential service provision. The sample selected from the all of 31 provinces of the country.  In each province, measures administered in Farsi. Within each area, the sample selected in 2 zones in order to provide a contrast between urban and rural places of residence.

3. Overall study design

In a first, screening and diagnostic stage, a random sample of the population of children aged 6 to 18 years surveyed with K- SADS-PL measures of known reliability and validity.  A multi-informant approach used and screening questionnaires simultaneously and independently completed by parents, and when aged 11 or more, by the youths themselves. This large body of data allow us to compare, on a range of individual behavioural and emotional items and scores, rates and patterns of deviance within and between the 31 provinces included in the survey and with non-Iranian samples surveyed with the same measures.

4. Selection of subjects

IRCAP project is a national project that implemented in all provinces of Iran. This project focused on the study of psychiatric disorders among 31,000 children and adolescents ages 6 to 18 years with semi- Structured interview K-SADS-PL. The sample size was calculated to provide an appropriate estimation in provinces. Assuming prevalence of psychiatric disorders equal 0.3 and type one error 0.05 and accepted error 0.05, the sample size for each province calculate equal to 825. We suggested the design effect for cluster sampling as 1.2; so the final sample size in each province increased to 990 (1000). The total sample size reached to 31000. 170 blocks (6 samples in each) in a province were selected. The multistage cluster sampling was considered for this study. In each province in addition to main city, rural places were selected randomly (as cluster sampling); in the next step, the blocks in provinces were selected randomly according to postal code. We had samples from urban and rural areas in provinces proportionally.

In addition to investigate the psychiatric disorders, millon clinical multiaxial inventory, social capital questionnaire and life style questionnaire were examined.

Scales

Kiddie-SADS-Present and Lifetime Version (K-SADS-PL)

Psychiatric disorders in children and adolescents were evaluated using the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (KSADS- PL) based on mother/main caregiver report. KSADS- PL is a semi-structured psychiatric interview that ascertains diagnostic status based on DSM-IV criteria including five diagnostic groups: 1) affective disorders (depression disorders [major depression, dysthymia] and mania, hypomania); 2) psychotic disorders; 3) anxiety disorders (social phobia/agoraphobia/specific phobia/obsessive- compulsive disorder/separation anxiety disorder/generalized anxiety disorder/panic disorder/posttraumatic stress disorder); 4) disruptive behavioral disorders (ADHD/conduct disorder/oppositional defiant disorder); and 5) substance abuse, tic disorders, eating disorders, and elimination disorders (enuresis/encopresis).

The aim of the interview is to establish rapport, obtain information about presenting complaints, prior psychiatric problems, and the child's global functioning. The interview opens with questions about basic demographics. Health and developmental history data should also be obtained, as this information may be helpful in making differential diagnoses.

Ghanizadeh and colleagues have reported the test-retest reliability of Persian version of this questionnaire to be 0.81 and the inter-rater reliability with 0.69 in which the sensitivity specificity of Persian version of K-SADS is shown to be high. The K-SADS-PL was used to diagnose ADHD and its psychiatric comorbidities. In the current study, all of the lifespan related psychiatric diagnoses were considered. In study of Polanczyk et al. that assess the interrater agreement for K-SADS, kappa coefficients were 0.93 (p<0.001) for affective disorders, 0.9 (p<0.001) for anxiety disorders, 0.94 (p<0.001) for attention-deficit/hyperactivity disorders and disruptive behavior disorders.

Millon Clinical Multiaxial Inventory - Third Edition (MCMI-III)

The Millon Clinical Multiaxial Inventory - Third Edition (MCMI-III) is the most recent edition of the Millon Clinical Multiaxial Inventory. The MCMI is a psychological assessment tool intended to provide information on personality traits and psychopathology, including specific psychiatric disorders outlined in the DSM-IV. It is intended for adults (18 and over) with at least a 5th grade reading level. The MCMI was developed and standardized specifically on clinical populations (i.e. patients in clinical settings or people with existing mental health problems).

The MCMI-III was published in 1994 and reflected revisions made in the DSM-IV. This version eliminated specific personality scales and added scales for depressive and PTSD bringing the total number of scales to 14 personality scales, 10 clinical syndrome scales, and 5 correction scales. The third edition is composed of 175 true-false questions that take approximately 20–25 minutes to complete. The inventory is almost self-administering.

Results of Blais and et al. suggest that the MCMI-III Avoidant scale is reliable (r =.89) and it was found to demonstrate appropriate convergent and divergent validity with other self-report measures. The MCMI-III Anxiety scale also showed adequate reliability (r =.78). Dyer (1997) concludes that the MCMI-III has content validity against the DSM-IV that is superior to any other major personality instrument.

Social capital questionnaire (Nahapyt and Ghoshal, 1998)

Social capital questionnaire of "Nahapyt and Ghushal" (1998) is included 28 questions that in total deals to the three dimensions of cognitive social capital, communication and structural. This questionnaire contains seven subscales such as: Networks, Trust, Cooperation, Mutual understanding, Relationships, Values, Commitment.

1. Cognitive elements: cognitive element of social capital refers to resources that provide the trappings, explanations an interprets and systems of common meanings among groups. The most important this dimension of these aspects of social capital include: language and common rules, common anecdotes (common experiences and memories).

2. The relational element: the relational element of social capital,is describing the kind of personal relations that individuals establish with each due to their interactions experience. The most important dimension of aspects of the social capital including: trust, norms, obligations and expectations and identity.

3. The structural element: the social capital element refers to the pattern of contacts between people, namely you to whom and how access has. The most important aspects of this element are: group relations, the configuration of group relations, appropriate organizations.

For determining the validity of questionnaires content validity has been used. Also professors' corrective opinions were applied in this field. In this research for investigation reliability the cronbach's alpha coefficient was used. The rate of social capital questionnaire reliability coefficient has been 85/0 that is showing this questionnaire optimal reliability. 89/0 is reliability coefficient of the cognitive social capital component, 9/0 relation social capital and 8/0 structural social capital.

Life Style Questionnaire (LSQ)

The LSQ was constructed by Lali et al. in Iran and its validity was confirmed through factor analysis. Its reliability was also assessed through internal consistency method and the Cronbach’s alpha ranged between 0.79 and 0.89 for different subscales. The LSQ is composed of 70 items in 10 subscales including physical health (8 items), sports and fitness (7 items), weight management and nutrition (7 items), disease prevention (7 items), mental health (7 items), spiritual health (6 items), social health (7 items), avoidance of drugs, alcohol and opiates (6 items), accident prevention (8 items) and environmental health (7 items). All items are responded on a four-point Likert scale scoring in range from 0 (= never) to 3 (= always). The higher the score, the better the lifestyle.

 

 OVERALL AIM OF THE STUDY

The main purpose of this study was to investigate the prevalence of psychiatric disorders in Iranian children and adolescents and its relationship to social capital, life style and parents' personality disorders.

Hypothesis

·  There is a relationship between the psychiatric disorders in Iranian children and adolescents and social capital.

·  There is a relationship between the psychiatric disorders in Iranian children and adolescents and life style.

·  There is a relationship between the psychiatric disorders in Iranian children and adolescents and parents' personality disorders.

The Study Objectives

-  To determine the prevalence of psychiatric disorders in children and adolescents

-  To determine the frequency of psychiatric disorders in children and adolescents according to demographic data (gender, age, education, parent education, economic situation)

-  To determine the assessment of social capital in children and adolescents

-  To determine the assessment of different lifestyles in children and adolescents

-  To determine the level of social capital in children and adolescents

-  To determine the prevalence of parents personality disorders

-  To determine the relationship between the psychiatric disorders and lifestyle in children and adolescents

-  To determine the relationship between the psychiatric disorders in children and adolescents and Parents personality disorders

-  To determine the relationship between the psychiatric disorders and social capital in children and adolescents

Applied objectives

§ Provide statistics on the prevalence of psychiatric disorders to health policy makers.

§ Identify children and adolescents at high risk of psychiatric disorders for primary prevention.

§ Organize workshops of life skills for positive cases. (In these workshops will be taught to people self-awareness, empathy, effective communication, interpersonal relations, decision making, problem solving, creative thinking, critical thinking, problem solving ability, ability to cope with stress.)

§ Organize workshops of appropriate life style for children and adolescents.

 

In Yazd Greater Area we selected 1035 cases and at first, psychologists gave invitations to parents who desired to have their children involved in this project. Finally, they referred to Afshar hospital to complete the K-SADS-PL, lifestyle scale and social capital scale. Also, in Afshar hospital we measured fasting blood sugar, lipid profile (the mean of triglycerides, total cholesterol, LDL and HDL), anthropometric indices (weight, height, body mass index, waist circumference and hip circumference) and systolic and diastolic blood pressure.

 

KEY WORDS: Child and Adolescent; Epidemiology; Psychiatric Disorders; Life Style; Social Capital; Parental Personality Disorders.

ETHICS:

The study was approved by NIMAD ethic committee (ethical code: IR.NIMAD.REC.1395.001) and Shahid Sadoughi University of Medical Sciences in Yazd, Iran (IR.SSU.Rec.1396.49).

First, the informed consent was taken from children and adolescents to participate in this study (the consent can be completed for participants younger than 15 years of age by their parents and for participants aged 15 to18 years by parents or by the adolescents). All information about children and adolescents and their families remained confidential.

If the disorder was diagnosed in children or adolescents, the child or adolescent psychiatrist who have collaborated in this project, treated them for free. If not possible or unwillingness of their parents, they were guided to refer to child and adolescent psychiatrists.

 

تاریخ به روز رسانی:
1397/12/08
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