Epidemiology of psychiatric
disorders in Iranian children and adolescents across the
country and its relationship with social capital, life
style and parents' personality disorders
Psychiatry and Psychology Research Center, Tehran University of Medical
Sciences, Tehran, Iran.
Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences,
3. Zanjan University of Medical Sciences, Zanjan, Iran.
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.
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:
assess the prevalence of child
psychological disorders in Iran;
To develop appropriate methods for
psychological assessment of children and adolescents in Iran;
determine the association of family and demographic variables with
To assess the needs for child mental health
services for Iran.
MATERIALS AND METHODS
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.
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.
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.
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.
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.
Overall study design
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.
Selection of subjects
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
addition to investigate the psychiatric disorders, millon clinical multiaxial inventory, social
capital questionnaire and life style questionnaire were examined.
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
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
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).
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
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.
There is a relationship between the psychiatric disorders in Iranian children and adolescents and social
· There is a relationship between the psychiatric
disorders in Iranian children and adolescents and
There is a relationship between the psychiatric disorders in Iranian children and adolescents and parents' personality
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,
- To determine the assessment of social capital in children and
- 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
§ 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
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.
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.
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.