Child mental health problems in the Gaza strip

Abdel Aziz Mousa Thabet: Projects Manager, Gaza community Mental Health Programme, PO Box 1049, Gaza, Palestine

Panos Vostanis ) : Senior Lecturer in Child and Adolescent Psychiatry, University of Birmingham, Parkview Clinic, Queensbridge Road, Moseley, Birmingham B13 8QE, United Kingdom, Tel: 0121 243 2035, Fax: 0121 243 2036

This study describes the mental health characteristics of 150 children of 6-13 years of age, who had been referred to different types of services in the Gaza strip: a community mental health centre, five primary health centres and a paediatric hospital. There was a high rate of somatising disorders among children referred to the mental health centre (42%). Parent-reported rates of significant mental health problems were high for all groups, i.e. 70% in the mental health centre group, 30% in the paediatric group, and 18% among children referred to primary health centres.

Children with mental health problems and disorders are seen by a variety of health services and health care professionals, often in an unco-ordinated way. A substantial proportion of cases are seen by community and hospital paediatricians, health visitors and school nurses (Kurtz et al, 1994; Health Advisory Service, 1995).

Garralda & Bailey found that 23% of children of 7-12 years of age attending general practice had psychiatric disorders, which were associated with family breakdown and parental stress. The same authors found a psychiatric prevalence of 28% among the same age group of referrals to general paediatrics, which was mainly accounted for by emotional disorders (two thirds of psychiatric disorders). The rate rose to 47% for reported psychological factors associated to somatic presentations (Garralda & Bailey, 1990).

Less is known about the rate and nature of child mental health problems seen in different health care settings in developing countries. In a two-stage study in Nigeria, Gureje et al (1994) found that 20% of children treated in paediatric primary care had a psychiatric disorder (6% depressive disorders, 4.7% anxiety-related disorders and 6.1% conduct disorders).

The study was completed in the Gaza strip, which had a population of 860,369 in 1995, excluding returnees from abroad after the peace process. The Gaza strip has a high population density of 2,150 people per km², which is a psychosocial risk factor for child psychopathology. The total refugee population is 62.6%. About 55.1% live in eight crowded camps, and 44.9% live in villages and towns. Half of the population (50.8%) are younger than 15 years of age. In 1995, the annual infant birth rate was 49.4 per 1000 population, the infant mortality rate was between 26-50 per 1000 infants, and the general population death rate was 8 per 1000. Respiratory diseases and diarrhoea are major causes of infant morbidity and mortality. The annual increase of population growth in the Gaza strip is 4.5%.

b) Five Primary Health Centres in Gaza and Rafah city. These primary health care settings are usually drop-in centres, without a referral procedure. In total, there are 31 primary health care centres distributed in the five districts of the Gaza strip, 10 of which operate a 24-hour service. The United Nations run similar clinics in the refugee camps in the Gaza strip. The majority of cases are seen by general practitioners, and there are weekly specialist clinics.

c) A Paediatric Hospital (Gaza El Naser - outpatient and inpatient departments). This is the only paediatric hospital in the Gaza strip, although there is one paediatric department at the Khan Younis General Hospital. The hospital has 240 beds, and accepts emergencies and routine out-patient referrals from the primary health centres.

Fifty consecutively referred children of 6-13 years were selected from each health care setting, excluding established cases of moderate to severe learning disability. Data were collected on family and socioeconomic status, and primary reason for referral. In addition, parents completed the Rutter Scales for their child (form A2, Arabic version). The Rutter Scales (Rutter et al, 1970) have been standardised and widely used as a measure of behavioural and emotional problems in epidemiological research. The scales consist of 31 items rating behavioural and emotional problems on a 0-2 scale. Children with a total score of 13 or more have been found to be potential ?cases?, i.e. presenting with a possible mental health disorder. Scores are also provided for the hyperactivity, conduct and neurotic subscales.

Out of the 150 children, 88 were male (59%) and 62 female (41%). The mean age was 8.9 years (range 6-13). The majority of families (N=121, or 80.7%) had at least four children. Large families (with at least four children) were more likely to be referred to the mental health service (x²=7.8, DF=2, p=0.02), which is consistent with previous findings that family overcrowding is a risk factor for child psychopathology. Forty two fathers (28%) were unemployed or unskilled workers, and four fathers (2.7%) had a criminal record. Eleven mothers (7.3%) had established psychiatric illness, these were evenly distributed among the three groups (x²=4.2, DF=2, p=0.12).

The psychiatric diagnoses as made by the clinician according to ICD-10 criteria (World Health Organisation, 1992) are presented in Table 1. Only two children seen at the paediatric hospital received a psychiatric diagnosis (conversion/hysteria) and none of those referred to a primary health centre. However, when presence of possible disorder was established by scores on the Rutter scales, prevalence rates were high among all groups. The rates of children whose total mental health care score indicated a disorder were: 70% of referrals to the mental health centre, 30% of referrals to the paediatric hospital, and 18% of children seen in primary health care (x²=32.9, DF=2, p<0.0005 - Table 2).

This study described the mental health characteristics of children referred to primary health, paediatric and psychiatric services in the Gaza strip. This is a heavily populated area and the child population carries several risk factors of developing psychiatric disorders, particularly the exposure to war trauma. Most health care services have been developed in the last few years, are well co-ordinated and accessible to children and families. Although the general health problems have not been described in this paper, the primary reasons for referral appeared appropriate both for general practice and hospital paediatrics.

The findings on child mental health problems highlight two interesting patterns. Firstly, children referred for general health problems had significant psychiatric morbidity of between 18-30% according to parental reports. This is similar to findings from studies in general practice and paediatric services in western societies, and indicates the need for liaison and consultation work by child and adolescent psychiatrists to other child health care professionals. Also, the need for incorporation of child psychiatry teaching in undergraduate and postgraduate curriculums, particularly in new universities and medical schools.

The nature and presentation of child mental healproblems ispossibly related to cultural factors. Many children seen at the mental health centre (N=21 or 42%) primarily had some

form of somatic presentation (particularly enuresis, which often underlies emotional and behavioural problems). In this group, it is important to establish the links between physical presentation, developmental delay and mental health symptoms (Garralda, 1996). Only three children had a primary clinical diagnosis of emotional disorder. The authors have recently reported on other samples of children and adolescents from the general population of the Gaza strip who, on more detailed investigation, were found to present with high rates of anxiety and post-traumatic stress disorders (Thabet & Vostanis, submitted for publication). As these services evolve, it is anticipated that emotional problems and disorders will be increasingly recognised, always in the cultural context of this society. For this reason, it would very interesting to repeat this study at a later stage.

GARRALDA, M.E. (1996) Somatisation in children. Journal of Child Psychology and

GARRALDA, M.E. & BAILEY, D. (1986) Children with psychiatric disorders in primary care. Journal of Child Psychology and Psychiatry, 27, 611-624.

GARRALDA, M.E. & BAILEY, D. (1989) Psychiatric disorders in general paediatric referrals. Archives of Disease in Childhood, 64, 1727-1733.

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GUREJE, O., OMIGBODUN, 0.0., GATER, R., ACHA, A., IKUESAN, B.A. & MORRIS, J. (1994) Psychiatric disorders in a paediatric primary care clinic. British Journal of Psychiatry, 165, 527-530.

HEALTH ADVISORY SERVICE (1995) Child and adolescent mental health services. London: HMSO.

KURTZ, Z., THORNES, R. & WOLKIND S. (1994) Services for the mental health of children and young people in England. London: South Thames Regional Health Authority.

THABET, A.A. & VOSTANIS, P. (1998). Social adversities and anxiety disorders in the Gaza strip. Archives of Childhood Diseases, 78, 439-442.

WORLD HEALTH ORGANISATION (1992) The ICD-10 classification of mental and behavioural disorders. Geneva: WHO.

TABLE 1 / Child Psychiatric diagnosis (N=150)
Diagnosis	Mental Health Paediatric		Primary Health
	Centre (N=50)	Hospital (N=50)	Centre (N=50)
Depression Phobia Hysteria Post-traumatic stress Conduct disorder Hyperactivity Enuresis Encopresis Learning difficulty Specific language disorder	1 1 1 1 6 3 18 2 7 5	2

TABLE 2 / Child psychiatric scores (Rutter Scales, N=150)
	Mental Health Paediatric		Primary Health
	Centre (N=50)	Hospital (N=50)	Centre (N=50)
Disorder (above cut-off)* Mean conduct score Mean hyperactivity score* Mean neurotic score* Mean total score	35 (70%) 3.3 3.2 2.5 18.5	15 (30%) 1.2 2.2 1.5 10.0	9 (18%) 0.9 1.9 1.0 7.1
chi square: p<0.0005 Kruskal-Wallis One-Way ANOVA: p<0.0005 **Kruskal-Wallis One-Way ANOVA: p<0.01