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Epidemiology of psychiatric disorders in children and adolescents; in Tehran, 2017
Accepted Manuscript Title: Epidemiology of Psychiatric Disorders in Children and Adolescents; in Tehran, 2017 Authors: Ali Khaleghi, Mohammad Reza mohammadi, Atefeh Zandifar, Nastaran Ahmadi, Seyyed Salman Alavi, Ameneh Ahmadi, Javad Mahmoudi-Gharaei, Zahra Hooshyari, Ali Mostafavi, Mahbod Fadaei Fooladi, Neda Vahed, Marziyeh Razeghi, Alireza Zahmatkesh, Mehrdad Barzegari, Sepideh Akbarpoor, Alia Shakiba, Malihe Mobini, Rahim Badrfam PII: DOI: Reference:
S1876-2018(18)30541-0 https://doi.org/10.1016/j.ajp.2018.08.011 AJP 1516
To appear in: Received date: Revised date: Accepted date:
8-6-2018 23-7-2018 16-8-2018
Please cite this article as: Khaleghi A, mohammadi MR, Zandifar A, Ahmadi N, Alavi SS, Ahmadi A, Mahmoudi-Gharaei J, Hooshyari Z, Mostafavi A, Fooladi MF, Vahed N, Razeghi M, Zahmatkesh A, Barzegari M, Akbarpoor S, Shakiba A, Mobini M, Badrfam R, Epidemiology of Psychiatric Disorders in Children and Adolescents; in Tehran, 2017, Asian Journal of Psychiatry (2018), https://doi.org/10.1016/j.ajp.2018.08.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Epidemiology of Psychiatric Disorders in Children and Adolescents; in Tehran, 2017
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3, Ali Khaleghi1, Mohammad Reza mohammadi2, Atefeh Zandifar Nastaran Ahmadi4, Seyyed Salman Alavi5, Ameneh Ahmadi6, Javad Mahmoudi-Gharaei7, Zahra Hooshyari8, ali mostafavi9, Mahbod Fadaei Fooladi10, Neda Vahed11, Marziyeh Razeghi12, Alireza Zahmatkesh13,
Mehrdad Barzegari14, Sepideh Akbarpoor15, Alia Shakiba16 , Malihe
Mobini17
1Psychiatry
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and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
2Psychiatry
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and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
3Assistant
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Professor of Psychiatry, Emam Hossein Hospital, Karaj university of medical sciences, Alborz, Iran)
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Yazd Cardiovascular Research Center, ShahidSadoughi University of Medical Sciences, Yazd, Iran)
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Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
6(1-
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Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
7(Psychiatry
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
8(Psychiatry
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
9(Psychiatry
10(Department
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and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
of psychology and educational science, Allameh Tabataba'i University,
Tehran, Iran)
11(Department
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of Mental Health, School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Tehran, Iran)
of psychology and educational science, Allameh Tabataba'i University,
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of Clinical Psychology, Azad Tehran University of Medical Sciences,
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13(Department
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Tehran, Iran)
of Clinical Psychology, Azad Tehran University of Medical Sciences,
Tehran, Iran)
of Clinical Psychology, Azad Garmsar University, Garmsar, Iran)
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15(Department
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Tehran, Iran)
16(Psychiatry
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and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
17(1-
Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
Highlights
The present study was performed on children and adolescents in Tehran during 2017. The overall prevalence of psychiatric disorders was 28.2% and mood disorders had the highest comorbidity with the others. The most commonly diagnosed disorders were anxiety disorders followed by behavioral disorders.
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Abstract
Objective: This survey was conducted to investigate the prevalence of various psychiatric disorders among children and adolescents aged 6 to 18 years in urban areas of Tehran.
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Methods: In the study, which was done with random sampling method, 2095 children and adolescents in the range seniors aged 6 to 18 years, have been studied and based on Persian version of K-SADS-PL, we reviewed the psychiatric disorders related to them.
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Results: The overall prevalence of psychiatric disorders in children and adolescents was 28.2%. The most commonly diagnosed disorders were anxiety disorders (21.9%), followed by behavioral disorders (9.6%).
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Conclusion: According to the results, 28.2% of the children and adolescents in Tehran province had psychiatric disorders, that is with increasing rate, compared with similar studies. Therefore, as a public health policy, the necessary tools for identifying, preventing and treating psychiatric disorders in children and adolescents should be considered in Tehran.
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Keywords: adolescents, children, comorbidity, psychiatric disorders.
INTRODUCTION
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Iran, as a developing country is going through important social, cultural, and economic transitions which will influence its populations' mental health status.(Alavi, Mohammadi et al. 2010) Tehran metropolitan is the capital of Iran and its population according to official data from the National Statistic Center of Iran is around 13 million and 260 thousand which more than 95% live in urban areas.(database 2016) Living various ethnicities and cultures together in this city make the pattern of psychological and psychiatric disorders complicated. Children and adolescents mental health problems often have serious long-term debilitating effects. Monitoring and reporting childhood mental health problems and mental health services utilization over time provide important information to identify mental health related issues and to guide early intervention.(Wu, Dal Grande et al. 2016)
The worldwide prevalence of mental disorders or mental problems among children and adolescents is about 20% which in half of them the onset of the signs are before the age 14.(Database 2014)
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In 2008 , Shahrivar et al. investigated the prevalence of psychological problems in 5171 adolescents aged 12 to 17 years in some provinces in Iran as 14.2% and they reported that the highest prevalence of psychological problems in the five provinces was related to conduct problems (24%), and the lowest prevalence was related to social problems (5.76%).(Shahrivar, Mahmoodi et al. 2008) Also Alavi et al. investigated the overall prevalence of any psychiatric disorders among children (6 to 11 years old) in urban areas of Tehran in 2010 as 17.9%. Of them, Attention Deficit Hyperactivity Disorder (ADHD) (8.6 %), Oppositional Defiant Disorder (ODD) (7.3%), and separation anxiety disorder (SAD) (5.9 %),respectively, was the most frequent diagnoses.(Alavi,2010)
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Noorbala et al conducted a study to evaluate the psychosocial stresses and concerns of people living in Tehran as a survey on 6000 adult participants. Of the participants, 82.7% experienced at least 1 severe stress during the year before study. At that time, 45.6% of the participants had at least 1severe economic stress, 32.3% had at least 1 severe familyrelated stress, 28.8% had at least 1severe health-related stress, and 25.7% experienced at least 1 severe future-related stress. The most common psychosocial stressors experienced in the last year were concerns about personal/family future (53.7%), concerns about the financial and economic future (47.1%), and the high cost of living (41.7%). However, the most severe stresses were due to the participants’ concerns about family health (14.4%), personal/family futures (13.2%), and financial and economic future (12.7%). Furthermore, health status, subjective socio-economic status, and age were the most important predictors of severe stress experiences.(Noorbala, Rafiey et al. 2018)
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Data from epidemiological studies can provide cross‐sectional and secular estimates of the prevalence of psychopathology to support rational service development.(Georgiades, Paksarian et al. 2018)
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Considering the population density of Tehran and the high population living in urban areas of it and the growing socioeconomic and social challenges, the likelihood of a change in the prevalence and pattern of psychiatric disorders in Tehran metropolitan is in mind and it has been felt the more relevant programs to be conducted by health and public health politicians. Hence, this study was designed to respond to this need so that the results would lead to health policies for the prevention, treatment and care of psychiatric disorders in the age group of children and adolescents. In this study we aimed to survey the prevalence of psychiatric disorders among children and adolescents; in Tehran, Iran, 2017 .
Materials and Methods Study Design
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This was an analytical cross sectional study performed in Tehran and is a part of a larger national project, named: “Epidemiology of Psychiatric Disorders in Iranian Children and Adolescents” abbreviated to IRCAP which has been implemented in all states of Iran in 2017 . (Mohammadi, Ahmadi et al. 2017)Moreover, the National Institute for Medical Research Development (NIMAD) approved and financially supported this study. The principal executor of the project had conducted many large-scale surveys of psychiatric disorders and has particular expertise in utilizing the instruments used in this proposal. Moreover, the principal investigator and his colleagues reported the test-retest reliability and the inter-rater reliability of the Persian version of K-SADS, and found the sensitivity and specificity of the Persian version to be high .(Mohammadi, Ahmadi et al. 2016)
Inclusion and Exclusion Criteria
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In a community-based study, 2095 children and adolescents aged 6-18 years were randomly selected from Tehran province by multistage cluster sampling method (cluster and stratified random sampling). Then, 350 blocks were randomly collected. Of each cluster head, 6 cases were selected, with 3 cases of each gender in different age groups (6- 9 years, 10 -14 years, and 15- 18 years). The blocks were selected randomly according to postal code.
Data Collection
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Inclusion criteria were as follow: Being an Iranian citizen (In each province, people who resided at least one year in that province could participate in the project), and age range of 6 to18 years. Children and adolescents with severe physical illness were excluded.
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The clinical psychologists instructed and trained the researcher psychologists to complete the Persian version of Kiddie-Sads- Present and Lifetime Version (K-SADS-PL). Then trained psychologists referred to the children's home and interviewed them using the KSADS-PL. The time required to complete the K-SADS was about 30 to 40 minutes. In addition, demographic data including gender, age, education, parent education, and economic situation were obtained.
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Procedures
1. The Site:
Tehran is the most populated city in Iran, and has a total population of 13,267,637 inhabitants. The population is ethnically diverse with large groups of Persians, Turkish, Kurdish, Lorish, Baluchi and Arabic origins, which represents the population of the
country. The religion is Islam (98.8%), and Farsi is the official language (The only language used for writing in administrations and the main language used for teaching in schools). The study performed in urban areas of Tehran metropolitan in 2017. 2. Selection of Study Areas and Participants:
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This study was a part of the IRCAP survey that conducted in all districts of urban areas of Tehran, with characteristics such as different ethnicities mixed-culture, and economic wealth, allowing the detection of fine-tuned variations in the rates of individual behavioral and emotional problems in children; this might call for differential service provision. The sample was selected from urban places. Three hundred and fifty clusters from all districts of Tehran were randomly selected and in each cluster, 6 households were randomly selected. Totally 2095 children and adolescents between 6 to 18 years old were surveyed. 3. Overall Study Design:
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A random sample of the children aged 6 to 18 years was surveyed with the Persian version of K- SADS-PL which has been approved by a good reliability and validity. A multiinformant approach was used and the parents were asked to complete the screening questionnaires simultaneously and independently and the youths themselves were asked to complete the questionnaires if they were 11 years or older.
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Scales
Kiddie-SADS-Present and Lifetime Version (K-SADS-PL):
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KSADS- PL, the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version, is a semi-structured psychiatric interview that is based on DSM-IV criteria. "It contains 5 diagnostic groups: (Kieling, Baker-Henningham et al. 2011) affective disorders including depression disorders [major depression, dysthymia] and mania, hypomania;(Davies, Heyman et al. 2003) psychotic disorders(Mohammadi, Arman et al. 2013); anxiety disorders including social phobia, agoraphobia, specific phobia, obsessive- compulsive disorder, separation anxiety disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder ;(Bilenberg, Petersen et al. 2005) disruptive behavioral disorders including ADHD, conduct disorder, oppositional defiant disorder; and (Ford, Goodman et al. 2003)substance abuse tic disorders, eating disorders, and elimination disorders (enuresis/encopresis)(Kaufman, Birmaher et al. 1997). The interview was started with questions about basic demographic characteristics. Moreover, information about presenting complaints and prior psychiatric problems are also obtained .(Kaufman, Birmaher et al. 1997) The reliability of the Persian version of K-SADS-PL has been calculated by Ghanizadeh et al. and reported to be 0.81 and the inter-rater reliability was 0.69 using test-retest. The
sensitivity and the specificity of this questionnaire was also high.(Ghanizadeh 2008) The kappa coefficients were 0.93 (p<0.001) for affective disorders, 0.9 (p<0.001) for anxiety disorders, and 0.94 (p<0.001) for ADHD and disruptive behavior disorders as reported by the study of Polanczyk et al. (Polanczyk, Eizirik et al. 2003) Ethics
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The national institute for medical research development (NIMAD) supported this study (the ethics code of IR.NIMAD.REC.1395.001). Consent was obtained from children and adolescents (Consent was completed for participants younger than 15 years by their parents and for participants aged 15 to 18 years by parents or by the adolescents themselves.). Information about children and adolescents and their families was kept confidential. If children or adolescents were diagnosed with a psychiatric disorder, the child and adolescent psychiatrist, who collaborated on the IRCAP project, treated them out of charge. However, if the participants or their parents did not wish to use the free treatment, then, they were referred to other child and adolescent psychiatrists. Statistical Analysis
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Data were entered into the SPSS 16. To determine the frequency of psychiatric disorders in children and adolescents, we used descriptive analysis and 95% confidence interval. A p value of <0.05 was considered statistically significant.
RESULTS
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The present study was performed on children and adolescents (6 to 18 years old) in Tehran during 2017. Of 2095 individuals, 1077(51.4%) were boy and 1018(48.6%) were girl. The frequency of demographic variables of children and adolescents and their family history of psychiatric disorders and physical illness is shown in Table-1. In this sample, the psychiatric disorders were seen in 328 (30.5%) of boys and 262(25.7%) in girls. The overall prevalence of psychiatric disorders in children and adolescents was 28.2%.The highest percentages of psychiatric disorders in regards with parents’ education were among children of families whose parents had elementary education (38.3%) and their mothers were in the illiterate group (38.8%). The highest rate of psychiatric disorders in regards to parents job was in the group of unemployed fathers (30.8%) and mothers working in private centers (36.6%). The prevalence of psychiatric disorders was not related to those with psychiatric or physical illnesses in their fathers. (Table 2 and 3). Regarding the prevalence of age-related disorders, the highest prevalence was at the age of 17 years (35.7%) and after that was the age of 13 years (33.6%). (Figure 1) The most commonly diagnosed disorders were anxiety disorders (21.9%), followed by behavioral disorders (9.6%), tobacco use (5.5%), and elimination disorders (4.8%). (Figure2) Among the most common anxiety disorders, the most common subgroups were
specific phobias (9.9%), obsessive compulsive disorder (7.8%) and separation anxiety disorder (6.9%), respectively. In the subgroup of behavioral disorders, the most common disorders are attention deficit hyperactivity disorder with 85 cases (4.4%) and oppositional defiant disorder with 76 cases (3.9%), respectively (Table4 and figure 3). According to the findings, mood disorders and anxiety disorders had the highest
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comorbidity with the other psychiatric disorders. (Table5).
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Discussion:
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In this study, the prevalence of psychiatric disorders among children and adolescents in Tehran was studied. The largest number of participants in this study resided in urban areas. The prevalence of psychiatric disorders among children and adolescents in Tehran in our survey was 28.2 (95%CI: 26.28 to 30.12). The prevalence of disorders in the same study in Tehran at 2013 was 14.2%, while the rate in our study is about 2 times. Another study in Tehran at 2010 reported the prevalence about 17.9%, which in total, shows a clear increasing trend in psychiatric disorders in recent years in Tehran.
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The sharp increase in the prevalence of psychiatric disorders over the last few years in Tehran could be due to rapid cultural change) such as the expansion of the media and the rapidly changing cultural outcomes) and a large expansion of urbanization, and also due to socio-economic changes )such as the economic difficulties and the social consequences of it) in the people's situation, which, in turn, will lead to an aggravation of psychiatric disorder.
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Due to Noorbala et. al. ‘s study about the psychosocial stress in Tehran at 2017, 82.7% experienced at least 1 severe stress during the past year and they emphasized the necessity to take actions to reduce the prevalence of common severe stresses in Tehran. Noorbala et al. evaluated mental health changes among population aged 15 and above in Tehran during 16 years (between 1999 and 2015) and the results of this study showed that about one third of their sample population were supposed to suffer
from a mental disorder at 2015 and reported that the prevalence of common mental disorders has increased from 21.2% in 1999 to 31.7% in 2015.(Noorbala, Yazdi et al. 2017)They strongly recommended that public health authorities put more effort to ensure necessary requirements encompassing prevention and promotion of mental health of the Iranian population residing in Tehran province.
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In our study the overall prevalence of psychiatric disorders in Tehran children and adolescents was 28.2% compared with the two other studies in Tehran at 2008 and 2010 with 14.2% and 17.9% which indicates an increase of 1.9 and 1.6 equal to the two studies, which requires careful consideration of the aesthetics of this issue and the follow-up of prevention and control methods for the causes that affect this prevalence, by policy Mental Health Issues.
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Seyfe Hashemi et al. investigated the prevalence of mental health problems in children(6 to 12 years old) and reported average problem in urban population of Semnan (a nearby province of Tehran) as 19.3% at 2012 .(Hashemi, Yarian et al. 2015) That was lower than our study in Tehran(28.2%), which could be due to the difference in economic-social conditions existing between these two provinces, cultural conditions, the existence of demographic dispersion and the extent of environmental stressors in these two provinces of Iran.
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In similar study in China (Xiaoli, Chao et al. 2014) the prevalence of psychiatric disorders among children and adolescents was about 9.49, which is clearly less than the prevalence earned in our study but the highest number of psychiatric disorders seen as the anxiety disorder is the same in this study and our study. This indicates an outbreak of anxiety disorders among children, regardless of the overall prevalence of psychiatric disorders in this age group. In all above studies, like ours, depression disorders, ODD and ADHD were at a later rank. This may show the similar pattern of psychiatric disorders among children and adolescents regardless of ethnicity and culture.
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Anxiety disorders are among the most common psychiatric disorders among children and adolescents. The prevalence of these disorders is different among children and adolescents, according to age and diagnostic tools. These disorders affect 10% to 20% of children and adolescents, and the incidence of life expectancy in children and adolescents is 10% to 27% .(Benjamin James Sadock 2014)
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In our study, the prevalence of these disorders was 21.9%, which represents the highest expected level among psychiatric patients in this age range, and requires a serious attention in identifying cases with preventive and therapeutic interventions. Creswell et al., presenting that the anxiety disorders are associated with other psychiatric disorders throughout life, emphasized the high prevalence of these disorders.(Creswell, Waite et al. 2014)
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Mishra et al. reported an increase in anxiety disorders in the Eastern Uttar Pradesh in India by 15%. They reported an increased prevalence of these disorders in middle adolescent period and lower socioeconomic groups. (Mishra, Srivastava et al. 2018) Mohapatra et al., In 2013, reported that anxiety disorders are the most common psychiatric disorders(Mohapatra, Agarwal et al. 2013). Sam Cartwright et al. in 2005, reported prevalence of anxiety disorders , with a handful of epidemiological studies on the prevalence of them in young populations, with a range of 2.6% and 41/2% . Also, they reported that the prevalence of these disorders is more than other disorders such as depression and probably behavioral disorders.(CartwrightHatton, McNicol et al. 2006) They suggested that the reasons for this wide range of anxiety disorders reports be evaluated, focusing on the different methods used to measure.
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Gonzales et al., In 2018, reviewed the psychiatric disorders associated with Internet gambling disorders and pathological video-Game use and noted the correlation between them and anxiety disorders of 92%. They emphasized the closer survey of this correlation.(González-Bueso, Santamaría et al. 2018)
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In our study, the prevalence of anxiety disorders was 21/9 %, which was the most prevalent among psychiatric disorders in children and adolescents. The evaluation of causes, attention to the specific behavioral characteristics of this age group, and the prevention, identification and treatment of cases by health policy programs seems to be much needed. Serinath et al., In 2005, surveyed the prevalence of psychiatric disorders in urban and rural areas in a region of India, of which 12.5% were reported. They described the higher prevalence of disturbances in middle class urban areas. Enuresis, specific phobia and hyperkinetic disorder were reported as the most common disorders.(Srinath, Girimaji et al. 2005)
In a meta-analysis ,in 2014,Malhotra et al. reported the prevalence of psychiatric disorders among children and adolescents in the general population 6/46% and schoolchildren 23/33%.(Malhotra and Patra 2014)
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In the study of Cortina et al., in 2012, the prevalence of mental health problems among children in Africa was studied and the prevalence of 14.3% in the general population, based on clinical diagnostic tools, and 8.8% based on screening questionnaires were reported. This study emphasized the relationship between sociodemographic factors and psychopathology. (Cortina, Sodha et al. 2012)
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As we see in the recent study, part of the high prevalence of psychiatric disorders in our study can be due to the impact of the special sociodemographic factors determinants of our study areas. ( For example, the meaningful more prevalence of psychiatric disorders among children and adolescents whose mother had history of physical illness(p value=0.001)).
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In the study by Fleitlich-Bilyk et al. on the prevalence of child and adolescent psychiatric disorders in southeast Brazil, the overall prevalence of DSMIV disorders was 12.7% (Fleitlich-Bilyk and Goodman 2004)which clearly shows a lower incidence than our study (12.7% versus 28.2%).They estimated that approximately one in eight school-age children in the study area in the southeast of Brazil have psychiatric disorders involving a level of distress or social impairment likely to warrant treatment . This estimation in our study was about 2.25 in eight person that is obviously more than that study.
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In the study by Wichstrom et al. at 2012 in Norway on Prevalence of psychiatric disorders in preschool age children(Wichstrøm, Berg‐Nielsen et al. 2012), they reported that in those with lower economic social status, more emotional and behavioral disorders were seen as we see in our study about the children and adolescent whose father jobs were in the position of “unemployed” and of being in low socioeconomic status. Also they reported that Comorbidity among disorders was common as we received in our study. In our study, in the age group of 13 and 17, there is a two-peak increase in the prevalence of psychiatric disorders (33.6% prevalence at age 13 and 35.7% at age 17). Patricia Cohen et al. point to the relationship between the prevalence of psychiatric disorders with age and gender. They point to the influence of age and
gender on the formulation of specific diagnostic patterns of disorders. They also suggest the potential impact of onset of puberty on aggravating major depression symptom . (Cohen, Cohen et al. 1993)
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In 2010, Merikangas et al. serveyed the lifetime prevalence of mental illness among adolescents. They emphasized the proportion of age with some psychiatric disorders. For example, the average age of the onset of mood disorders was 13 years of age and behavioral disorders at the age of 11 years. (Merikangas, He et al. 2010) Loeber et al., also emphasized the influence of age and gender as effective factors on pattern of comorbidity with conduct disorder.(Loeber and Keenan 1994)
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The reason for the existence of two age peak on psychiatric disorders in our study can be attributed to the intensification of the puberty process in this age group among girls (13 years) (Razzaghy-Azar, Moghimi et al. 2006) and boys (17 years) (Ahmadi, Anoosheh et al. 2009) and it’s effect on the mental health status of adolescents and their outcomes.
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Also, the stress of participating in the general entrance exam in governmental and nongovernmental universities in Iran, which is held in the last year of high school, and the results of this stress on increased prevalence of psychiatric disorders, can be due to the increase disturbances in this peak age. (Yousefi, Talib et al. 2010)
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Conclusion: According to the results, more than a quarter (28.2%) of the children and adolescents in Tehran province had psychiatric disorders that is with increasing rate compared with similar studies conducted in Tehran at 2008 (14.2% ) in adolescents and at 2010(17.9%) in children. Therefore, as a public health policy, the necessary tools for identifying, preventing and treating psychiatric disorders in children and adolescents should be considered in Tehran.
Limitations This study is one of the most comprehensive epidemiological studies to investigate the prevalence of psychiatric disorders in Tehran's children and adolescents in different districts of the capital of Tehran. In order to obtain accurate information on the prevalence of psychiatric disorders in children and adolescents throughout the province
of Tehran, it is possible to evaluate the prevalence of these disorders in all cities of the province.
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Conflict of Interest No conflict of interest.
Ethics
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The national institute for medical research development (NIMAD) supported this study (the ethics code of IR.NIMAD.REC.1395.001). Consent was obtained from children and adolescents (Consent was completed for participants younger than 15 years by their parents and for participants aged 15 to 18 years by parents or by the adolescents themselves.). Information about children and adolescents and their families was kept confidential. If children or adolescents were diagnosed with a psychiatric disorder, the child and adolescent psychiatrist, who collaborated on the IRCAP project, treated them out of charge. However, if the participants or their parents did not wish to use the free treatment, then, they were referred to other child and adolescent psychiatrists
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Funding
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This work was supported by the National Institute for Medical Research Development (NIMAD) (Grant No. 940906)
Acknowledgements
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We would like to thank all the families and the children who participated for their cooperation. We also thank the National Institute for Medical Research Development (NIMAD) (Grant No. 940906) and the Psychiatry and Psychology Research Center, Tehran University of Medical Sciences for their financial and non-financial supports. Furthermore, we would like to thank all the interviewers involved in the project.
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Merikangas, K. R., et al. (2010). "Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A)." Journal of the American Academy of Child & Adolescent Psychiatry 49(10): 980-989. Mishra, S. K., et al. (2018). "Prevalence of depression and anxiety among children in rural and suburban areas of Eastern Uttar Pradesh: A cross-sectional study." Journal of family medicine and primary care 7(1): 21.
Mohammadi, M. R., et al. (2017). "Epidemiology of Psychiatric Disorders in Iranian Children and Adolescents (IRCAP) and Its Relationship with Social Capital, Life Style and Parents' Personality Disorders: Study Protocol." Iranian Journal of Psychiatry 12(1): 66.
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Mohammadi, M. R., et al. (2016). "Psychiatric disorders in Iranian children and adolescents." Iranian Journal of Psychiatry 11(2): 87. Mohammadi, M. R., et al. (2013). "Psychological problems in Iranian adolescents: application of the self report form of strengths and difficulties questionnaire." Iranian Journal of Psychiatry 8(4): 152. Mohapatra, S., et al. (2013). "Pediatric anxiety disorders." Asian journal of psychiatry 6(5): 356-363.
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Noorbala, A. A., et al. (2018). "Psychosocial Stresses and Concerns of People Living in Tehran: A Survey on 6000 Adult Participants." Iranian Journal of Psychiatry 13(2): 94.
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Noorbala, A. A., et al. (2017). "A Survey on Mental Health Status of Adult Population Aged 15 and above in the Province of Tehran, Iran." Archives of Iranian medicine 20(11): S115-S118.
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Polanczyk, G. V., et al. (2003). "Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E)." Revista Brasileira de Psiquiatria 25(2): 87-90.
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Razzaghy-Azar, M., et al. (2006). "Age of puberty in Iranian girls living in Tehran." Annals of Human Biology 33(5-6): 628-633.
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Shahrivar, Z., et al. (2008). "Prevalence of psychiatric disorders amongst adolescents in Tehran." Iranian Journal of Psychiatry 3(3): 100-104.
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Srinath, S., et al. (2005). "Epidemiological study of child & adolescent psychiatric disorders in urban & rural areas of Bangalore, India." Indian Journal of Medical Research 122(1): 67.
A
Wichstrøm, L., et al. (2012). "Prevalence of psychiatric disorders in preschoolers." Journal of Child Psychology and Psychiatry 53(6): 695-705. Wu, J., et al. (2016). "Parent-reported Mental Health Problems and Mental Health Services Use in South Australian School-aged Children." AIMS public health 3(4): 750. Xiaoli, Y., et al. (2014). "Prevalence of psychiatric disorders among children and adolescents in northeast China." PLoS One 9(10): e111223.
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Yousefi, F., et al. (2010). "The relationship between test-anxiety and academic achievement among Iranian adolescents." Asian Social Science 6(5): 100.
A
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M
A
N
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This work was supported by the National Institute for Medical Research Development (NIMAD) (Grant No. 940906)
PREVALENCE OF CHILD AND ADOLESCENTS PSYCHIATRIC DISORDER IN TEHRAN PROVENIENCE 9.9 7.8
SC RI PT
6.9
5.5 5.2 4.7 4.4 3.9
N
A
0.7 0.7 0.6 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.1 0.1
U
2.8 2.8 2.3 1.9 1.9
TE
D
M
SPECIFIC PHOBIAS OBSESSIVE COMPULSIVE DISORDER SEPARATION ANXIETY DISORDER TOBACCO USE AGORAPHOBIA ENURESIS ATTENTION DEFICIT HYPERACTIVITY DISORDER OPPOSITIONAL DEFIANT DISORDER TIC DISORDER GENERALIZED ANXIETY DEPRESSIVE DISORDERS EPILEPSY SOCIAL PHOBIA CONDUCT DISORDER HYPOMANIA MENTAL RETARDATION POST-TRAUMATIC STRESS DISORDER MANIA BULIMIA NERVOSA AUTISM PSYCHOSIS ALCOHOL ABUSE PANIC DISORDER ANOREXIA NERVOSA ENCOPRESIS
0
2
4
6
8
10
A
CC
EP
Figure 1: Prevalence of psychiatric disorders in children and adolescents Tehran provenience
12
ALCOHOL ABUSE
0.2
EATING DISORDERS
0.3
PSYCHOSIS
0.3
NEURODEVELOPMENTAL DISORDERS
SC RI PT
CHART TITLE
2.5
MOOD DISORDERS
2.8
ELIMINATION DISORDERS
4.8
TOBACCO USE
5.5
BEHAVIORAL DISORDERS
U
9.6
5
10
21.9 15
20
25
A
0
N
ANXIETY DISORDERS
TE
D
M
Figure 2: Prevalence of psychiatric disorders in children and adolescents Tehran provenience
EP
29.2
27.4
33.6 31
28.3
30 28
27.8 26.1
27
CC
26.9
35.7
A
20.2
6
7
8
9
10
11
12
13
14
15
16
17
18
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Figure 3: prevalence of child and adolescents psychiatric disorder by age tends
Demographic variables
place of residence Father education
A
M
D
Father job
TE
Mother job
Father history of psychiatric disorder Mother history of psychiatric disorder Father history of physical illness Mother history of physical illness Total
EP Health variables
CC A
Percent 51.4 48.6
781 843 471 2083 12 38 175
37.3 40.2 22.5 99.4 .6 2.0 9.0
365
18.8
714 456 193
154 49 161
2.5 8.2
13.7
864 511 116
43.8 25.9 5.9
123
Public sector Private sector unemployed
685 1227 39
Missing
144
Public sector Private sector
268 82 1629
unemployed (Housewife) Missing Yes No Missing Yes No Missing Yes No Missing Yes No Missing
36.8 23.5 9.9
271
N
Mother education
n 1077 1018
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Age
Boy Girl 6-9 10-14 15-18 Urban Rural Illiterate primary school Guidance or high school Diploma bachelor MSc or higher Missing Illiterate primary school Guidance or high school Diploma bachelor MSc or higher Missing
U
Sex
35.1 62.9 2.0 13.5 4.1 82.3
116 2076 18
99.1 .9
1 2064 29
98.6 1.4
2 1845 212
89.7 10.3
38 1802 252
87.7 12.3
41 2095
100
Table 1: Frequency of Demographic Variables in Children and Adolescents (6-18) of Tehran provenience
Variables
32.6
200 116
28 25.4
50
25.9
26 19
38.8
52
32.3
91
Father history of psychiatric disorder Mother history of psychiatric disorder Father history of physical illness
8.829
0.116
31.81 31.7 46.42
0.199
0.905
2.726
0.256
0.001
0.970
0.575
0.448
30.06 34.22
0.002
0.966
28.5
12.146
0.001
45.67 37.57 31.41 29.63 32.52
26.43 25.56
52.76
33.6
28.22
39.4
28.7 25.6
25.78 22.05 20.27
31.81 29.6
32
27.6
39.86
36.34
123
22.26 26.98
32.86 47.4
469
28.8
26.64
31.04
18 585
28.2
26.29
30.15
No
5
27.8
12.5
50.87
Yes
580
28.1
26.2 19.94
30.08
No
10
34.5
Yes No
516 59
28 27.8
Missing
15
Yes
476
EP A
CC
Mother jobs
unemployed (Housewife) Missing Yes
0.163
0.017
27.2 36.6
Missing
3.626
13.778
25.07 26.63 18.57
Public sector Private sector
0.016
154
248 131
17 194 357 12 27 73 30
24.84 21.66 20.24
5.759
0.690
28.3 29.1 30.8
TE
Father jobs
Public sector Private sector unemployed
27.99
Sig
SC RI PT
119
D
Mother educations
38.3
Chi Sq.
0.160
U
Father educations
67
31.41
N
place of residence
CI (95%) min max 27.78 33.26 23.15 28.51 22.80 28.92 26.67 32.83 25.57 33.78 26.24 30.1 13.81 60.93 19.09 47.46
A
Age
Boy Girl 6-9 10-14 15-18 Urban Rural Illiterate primary school Guidance & high school Diploma bachelor MSc or higher Missing Illiterate primary school Guidance & high school Diploma bachelor MSc or higher Missing
M
Sex
with disorder n percent 328 30.5 262 25.7 201 25.7 250 29.7 139 29.5 586 28.1 4 33.3 12 31.6
144
116
52.65 25.97 22.23
38 26.4
24.44
Mother history of physical illness
No
93
31.18
36.9
43.01
41 Missing Total
21 590
28.2
26.28
30.12
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Table 2: Prevalence of Psychiatric Disorders in sample of Tehran provenience in Terms of Demographic
P-value
OR (adjusted)
CI (95%)
P-value
female
0.79
0.65-0.96
0.017
0.81
0.67-0.99
0.043
6-9 10-14
1.00 Baseline 1.22
0.98-1.51
0.078
1.120
0.89-1.41
0.33
15-18
1.21
0.94-1.56
0.146
1.092
0.84-1.43
0.52
Urban
1.00 Baseline
0.769
0.52-1.14
0.19
0.643
0.43-0.96
0.031
High school
0.82
0.58-1.17
0.273
Diploma
0.66
0.48-0.91
0.012
bachelor
0.58
0.41-0.82
0.002
0.526
0.33-0.84
0.008
MSc or higher
0.59
0.39-0.91
0.016
0.29-0.92
0.024
Illiterate & primary school
1.00 Baseline
N
0.515
High school
0.99
0.68-1.45
0.96
1.132
0.74-1.72
0.57
Diploma
0.79
0.57-1.09
0.15
1.008
0.67-1.51
0.97
Bachelor
0.68
0.48-0.96
0.027
0.984
0.61-1.58
0.95
Msc or higher
D
0.45-1.23
0.25
0.949
0.49-1.84
0.88
0.84-1.28 0.56-2.26
0.72 0.74
0.833 0.901
0.65-1.06 0.43-1.89
0.14 0.78
0.91-2.60 0.81-1.44
0.11 0.61
1.493 0.931
0.85-2.62 0.66-1.32
0.16 0.69
0.35-2.76
0.97
0.97
0.30-3.16
0.96
0.62-2.91
0.45
1.24
0.52-2.95
0.62
0.72-1.36
0.96
0.95
0.68-1.32
0.76
1.24-2.15
0.001
1.64
1.23-2.17
0.001
M
TE
0.75
Public sector
Private sector unemployed Public sector
A
CC
Private sector Unemployed (Housewife) Father history of no psychiatric disorder yes Mother history of no psychiatric disorder yes Father history of no physical illness yes Mother history of no physical illness yes
OR adjusted: Odds Ratio CI: Confidence Interval
1.00 Baseline 1.04 1.13 1.00 Baseline 1.54 1.08 1.00 Baseline 0.98 1.00 Baseline 1.35 1.00 Baseline 0.99 1.00 Baseline 1.63
U
1.00 Baseline
A
Illiterate & primary school
EP
Locus of life Father education Mother education Mother job
Father job
Demographic variables Health variables
Rural
SC RI PT
OR (crude) 1.00 Baseline
CI (95%)
male
Age group
Sex
Variables and their categories
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Table 3. Odds Ratios (95% CI) for total psychiatric disorder in term of demographic and health variables
Confidence Interval
Psychiatric Disorders
Mania Hypomania Total Mood Disorders Psychosis
8 14 54 5
Panic Disorder Separation Anxiety Disorder Social Phobia Specific Phobias Agoraphobia Generalized Anxiety Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Total Anxiety Disorders Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Tic Disorder Total Behavioral Disorders Autism Mental retardation Epilepsy
3 135
M
D
TE
Neurodevelopm ental disorders
Total Neurodevelopmental disorders
CC
EP
Substance abuse disorders
A
Elimination Disorders
Eating Disorders
Total
Tobacco use Alcohol abuse Drug abuse Total Substance abuse disorders Enuresis Encopresis Total Elimination Disorders Anorexia Nervosa Bulimia Nervosa Total Eating Disorders
Min
Max
1.76
3.13
0.4 0.7 2.8 0.3
0.2 0.4 2.2 0.1
0.8 1.2 3.6 0.6
0.2 6.9
0.05 5.88
0.4 8.13
1.9 9.9 5.2 2.8 7.8
1.37 8.69 4.27 2.12 6.66
2.57 11.35 6.24 3.58 9.03
0.4
0.2
0.8
411 85
21.9 4.4
20.04 3.55
23.77 5.37
76
3.9
3.1
4.82
14 55 185
0.7 2.8 9.6
0.4 2.16 8.36
1.2 3.63 11
6 13 40 48
0.3 0.6 1.9 2.5
0.14 0.36 1.41 1.85
0.67 1.06 2.59 3.23
116 4
5.5 0.2
4.64 0.09
6.6 0.6
117
5.6
4.68
6.65
93 1 94
4.7 0.1 4.8
3.88 0.01 3.93
5.76 0.3 5.83
1 5 6
0.1 0.3 0.3
0.01 0.12 0.15
0.03 0.63 0.7
590
28.2
26.66
30.56
37 194 101 54 152 8
A
Behavioral Disorders
percent 2.3
SC RI PT
Anxiety Disorders
Number 45
U
Psychotic Disorders
Depressive Disorders
N
Mood Disorders
Table4: Prevalence and Confidence Interval of Psychiatric Disorders in the Tehran provenience children and adolescents (6-18)
Eating Disorders F(P)
Elimination Disorders F(P)
Substance abuse disorders F(P)
Neurodevelopm ental disorders F(P)
Behavioral Disorders F(P)
Anxiety Disorders F(P)
Psychotic Disorders F (P)
1(1.9)
3(5.6)
8(21.6)
2(3.7)
18(36)
32(66.7)
5(9.3)
0
0
0
0
3(60)
4(80)
5(1.3)
33(8.1)
23(6.8)
12(3)
81(20.1)
0
21(11.5)
19(13.5)
11(6)
0
5(11.6)
2(5.6)
1(0.9)
12(10.5)
3(1.6)
18(10.2)
11(26.8)
12(30)
0
2(4.8)
2(1.8)
19(17.3)
23(21.7)
0
8(7.3)
12(14.6)
5(5.4)
21(24.4)
33(37.9)
0
3(3.4)
1(33.3)
0
0
5(83.3)
0
1(16.7)
A M D TE EP CC
Psychotic Disorders
SC RI PT
81(46.6)
Table 5: Comorbidity disorders according to the type of psychiatric disorder in the Tehran provenience
A
Main disorder
5(100) 32(8.1)
N
1(16.7)
Comorbid disorder
Mood Disorders
4(1)
U
1(1.1)
Mood Disorders F (P)
Anxiety Disorders Behavioral Disorders Neurodevelopme ntal disorders Substance abuse disorders Elimination Disorders Eating Disorders
S1876-2018(18)30541-0 https://doi.org/10.1016/j.ajp.2018.08.011 AJP 1516
To appear in: Received date: Revised date: Accepted date:
8-6-2018 23-7-2018 16-8-2018
Please cite this article as: Khaleghi A, mohammadi MR, Zandifar A, Ahmadi N, Alavi SS, Ahmadi A, Mahmoudi-Gharaei J, Hooshyari Z, Mostafavi A, Fooladi MF, Vahed N, Razeghi M, Zahmatkesh A, Barzegari M, Akbarpoor S, Shakiba A, Mobini M, Badrfam R, Epidemiology of Psychiatric Disorders in Children and Adolescents; in Tehran, 2017, Asian Journal of Psychiatry (2018), https://doi.org/10.1016/j.ajp.2018.08.011 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Epidemiology of Psychiatric Disorders in Children and Adolescents; in Tehran, 2017
SC RI PT
3, Ali Khaleghi1, Mohammad Reza mohammadi2, Atefeh Zandifar Nastaran Ahmadi4, Seyyed Salman Alavi5, Ameneh Ahmadi6, Javad Mahmoudi-Gharaei7, Zahra Hooshyari8, ali mostafavi9, Mahbod Fadaei Fooladi10, Neda Vahed11, Marziyeh Razeghi12, Alireza Zahmatkesh13,
Mehrdad Barzegari14, Sepideh Akbarpoor15, Alia Shakiba16 , Malihe
Mobini17
1Psychiatry
N
U
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
2Psychiatry
M
A
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
3Assistant
TE
D
Professor of Psychiatry, Emam Hossein Hospital, Karaj university of medical sciences, Alborz, Iran)
4(3-
5(1-
EP
Yazd Cardiovascular Research Center, ShahidSadoughi University of Medical Sciences, Yazd, Iran)
CC
Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
6(1-
A
Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
7(Psychiatry
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
8(Psychiatry
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
9(Psychiatry
10(Department
SC RI PT
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
of psychology and educational science, Allameh Tabataba'i University,
Tehran, Iran)
11(Department
12(Department
U
of Mental Health, School of Behavioral Sciences and Mental Health, Tehran Institute of Psychiatry, Tehran, Iran)
of psychology and educational science, Allameh Tabataba'i University,
A
of Clinical Psychology, Azad Tehran University of Medical Sciences,
M
13(Department
N
Tehran, Iran)
of Clinical Psychology, Azad Tehran University of Medical Sciences,
Tehran, Iran)
of Clinical Psychology, Azad Garmsar University, Garmsar, Iran)
EP
15(Department
TE
14(Department
D
Tehran, Iran)
16(Psychiatry
A
CC
and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
17(1-
Psychiatry and psychology research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran)
Highlights
The present study was performed on children and adolescents in Tehran during 2017. The overall prevalence of psychiatric disorders was 28.2% and mood disorders had the highest comorbidity with the others. The most commonly diagnosed disorders were anxiety disorders followed by behavioral disorders.
SC RI PT
Abstract
Objective: This survey was conducted to investigate the prevalence of various psychiatric disorders among children and adolescents aged 6 to 18 years in urban areas of Tehran.
U
Methods: In the study, which was done with random sampling method, 2095 children and adolescents in the range seniors aged 6 to 18 years, have been studied and based on Persian version of K-SADS-PL, we reviewed the psychiatric disorders related to them.
N
Results: The overall prevalence of psychiatric disorders in children and adolescents was 28.2%. The most commonly diagnosed disorders were anxiety disorders (21.9%), followed by behavioral disorders (9.6%).
TE
D
M
A
Conclusion: According to the results, 28.2% of the children and adolescents in Tehran province had psychiatric disorders, that is with increasing rate, compared with similar studies. Therefore, as a public health policy, the necessary tools for identifying, preventing and treating psychiatric disorders in children and adolescents should be considered in Tehran.
EP
Keywords: adolescents, children, comorbidity, psychiatric disorders.
INTRODUCTION
A
CC
Iran, as a developing country is going through important social, cultural, and economic transitions which will influence its populations' mental health status.(Alavi, Mohammadi et al. 2010) Tehran metropolitan is the capital of Iran and its population according to official data from the National Statistic Center of Iran is around 13 million and 260 thousand which more than 95% live in urban areas.(database 2016) Living various ethnicities and cultures together in this city make the pattern of psychological and psychiatric disorders complicated. Children and adolescents mental health problems often have serious long-term debilitating effects. Monitoring and reporting childhood mental health problems and mental health services utilization over time provide important information to identify mental health related issues and to guide early intervention.(Wu, Dal Grande et al. 2016)
The worldwide prevalence of mental disorders or mental problems among children and adolescents is about 20% which in half of them the onset of the signs are before the age 14.(Database 2014)
SC RI PT
In 2008 , Shahrivar et al. investigated the prevalence of psychological problems in 5171 adolescents aged 12 to 17 years in some provinces in Iran as 14.2% and they reported that the highest prevalence of psychological problems in the five provinces was related to conduct problems (24%), and the lowest prevalence was related to social problems (5.76%).(Shahrivar, Mahmoodi et al. 2008) Also Alavi et al. investigated the overall prevalence of any psychiatric disorders among children (6 to 11 years old) in urban areas of Tehran in 2010 as 17.9%. Of them, Attention Deficit Hyperactivity Disorder (ADHD) (8.6 %), Oppositional Defiant Disorder (ODD) (7.3%), and separation anxiety disorder (SAD) (5.9 %),respectively, was the most frequent diagnoses.(Alavi,2010)
TE
D
M
A
N
U
Noorbala et al conducted a study to evaluate the psychosocial stresses and concerns of people living in Tehran as a survey on 6000 adult participants. Of the participants, 82.7% experienced at least 1 severe stress during the year before study. At that time, 45.6% of the participants had at least 1severe economic stress, 32.3% had at least 1 severe familyrelated stress, 28.8% had at least 1severe health-related stress, and 25.7% experienced at least 1 severe future-related stress. The most common psychosocial stressors experienced in the last year were concerns about personal/family future (53.7%), concerns about the financial and economic future (47.1%), and the high cost of living (41.7%). However, the most severe stresses were due to the participants’ concerns about family health (14.4%), personal/family futures (13.2%), and financial and economic future (12.7%). Furthermore, health status, subjective socio-economic status, and age were the most important predictors of severe stress experiences.(Noorbala, Rafiey et al. 2018)
CC
EP
Data from epidemiological studies can provide cross‐sectional and secular estimates of the prevalence of psychopathology to support rational service development.(Georgiades, Paksarian et al. 2018)
A
Considering the population density of Tehran and the high population living in urban areas of it and the growing socioeconomic and social challenges, the likelihood of a change in the prevalence and pattern of psychiatric disorders in Tehran metropolitan is in mind and it has been felt the more relevant programs to be conducted by health and public health politicians. Hence, this study was designed to respond to this need so that the results would lead to health policies for the prevention, treatment and care of psychiatric disorders in the age group of children and adolescents. In this study we aimed to survey the prevalence of psychiatric disorders among children and adolescents; in Tehran, Iran, 2017 .
Materials and Methods Study Design
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This was an analytical cross sectional study performed in Tehran and is a part of a larger national project, named: “Epidemiology of Psychiatric Disorders in Iranian Children and Adolescents” abbreviated to IRCAP which has been implemented in all states of Iran in 2017 . (Mohammadi, Ahmadi et al. 2017)Moreover, the National Institute for Medical Research Development (NIMAD) approved and financially supported this study. The principal executor of the project had conducted many large-scale surveys of psychiatric disorders and has particular expertise in utilizing the instruments used in this proposal. Moreover, the principal investigator and his colleagues reported the test-retest reliability and the inter-rater reliability of the Persian version of K-SADS, and found the sensitivity and specificity of the Persian version to be high .(Mohammadi, Ahmadi et al. 2016)
Inclusion and Exclusion Criteria
M
A
N
U
In a community-based study, 2095 children and adolescents aged 6-18 years were randomly selected from Tehran province by multistage cluster sampling method (cluster and stratified random sampling). Then, 350 blocks were randomly collected. Of each cluster head, 6 cases were selected, with 3 cases of each gender in different age groups (6- 9 years, 10 -14 years, and 15- 18 years). The blocks were selected randomly according to postal code.
Data Collection
TE
D
Inclusion criteria were as follow: Being an Iranian citizen (In each province, people who resided at least one year in that province could participate in the project), and age range of 6 to18 years. Children and adolescents with severe physical illness were excluded.
CC
EP
The clinical psychologists instructed and trained the researcher psychologists to complete the Persian version of Kiddie-Sads- Present and Lifetime Version (K-SADS-PL). Then trained psychologists referred to the children's home and interviewed them using the KSADS-PL. The time required to complete the K-SADS was about 30 to 40 minutes. In addition, demographic data including gender, age, education, parent education, and economic situation were obtained.
A
Procedures
1. The Site:
Tehran is the most populated city in Iran, and has a total population of 13,267,637 inhabitants. The population is ethnically diverse with large groups of Persians, Turkish, Kurdish, Lorish, Baluchi and Arabic origins, which represents the population of the
country. The religion is Islam (98.8%), and Farsi is the official language (The only language used for writing in administrations and the main language used for teaching in schools). The study performed in urban areas of Tehran metropolitan in 2017. 2. Selection of Study Areas and Participants:
SC RI PT
This study was a part of the IRCAP survey that conducted in all districts of urban areas of Tehran, with characteristics such as different ethnicities mixed-culture, and economic wealth, allowing the detection of fine-tuned variations in the rates of individual behavioral and emotional problems in children; this might call for differential service provision. The sample was selected from urban places. Three hundred and fifty clusters from all districts of Tehran were randomly selected and in each cluster, 6 households were randomly selected. Totally 2095 children and adolescents between 6 to 18 years old were surveyed. 3. Overall Study Design:
A
N
U
A random sample of the children aged 6 to 18 years was surveyed with the Persian version of K- SADS-PL which has been approved by a good reliability and validity. A multiinformant approach was used and the parents were asked to complete the screening questionnaires simultaneously and independently and the youths themselves were asked to complete the questionnaires if they were 11 years or older.
M
Scales
Kiddie-SADS-Present and Lifetime Version (K-SADS-PL):
A
CC
EP
TE
D
KSADS- PL, the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version, is a semi-structured psychiatric interview that is based on DSM-IV criteria. "It contains 5 diagnostic groups: (Kieling, Baker-Henningham et al. 2011) affective disorders including depression disorders [major depression, dysthymia] and mania, hypomania;(Davies, Heyman et al. 2003) psychotic disorders(Mohammadi, Arman et al. 2013); anxiety disorders including social phobia, agoraphobia, specific phobia, obsessive- compulsive disorder, separation anxiety disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder ;(Bilenberg, Petersen et al. 2005) disruptive behavioral disorders including ADHD, conduct disorder, oppositional defiant disorder; and (Ford, Goodman et al. 2003)substance abuse tic disorders, eating disorders, and elimination disorders (enuresis/encopresis)(Kaufman, Birmaher et al. 1997). The interview was started with questions about basic demographic characteristics. Moreover, information about presenting complaints and prior psychiatric problems are also obtained .(Kaufman, Birmaher et al. 1997) The reliability of the Persian version of K-SADS-PL has been calculated by Ghanizadeh et al. and reported to be 0.81 and the inter-rater reliability was 0.69 using test-retest. The
sensitivity and the specificity of this questionnaire was also high.(Ghanizadeh 2008) The kappa coefficients were 0.93 (p<0.001) for affective disorders, 0.9 (p<0.001) for anxiety disorders, and 0.94 (p<0.001) for ADHD and disruptive behavior disorders as reported by the study of Polanczyk et al. (Polanczyk, Eizirik et al. 2003) Ethics
U
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The national institute for medical research development (NIMAD) supported this study (the ethics code of IR.NIMAD.REC.1395.001). Consent was obtained from children and adolescents (Consent was completed for participants younger than 15 years by their parents and for participants aged 15 to 18 years by parents or by the adolescents themselves.). Information about children and adolescents and their families was kept confidential. If children or adolescents were diagnosed with a psychiatric disorder, the child and adolescent psychiatrist, who collaborated on the IRCAP project, treated them out of charge. However, if the participants or their parents did not wish to use the free treatment, then, they were referred to other child and adolescent psychiatrists. Statistical Analysis
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Data were entered into the SPSS 16. To determine the frequency of psychiatric disorders in children and adolescents, we used descriptive analysis and 95% confidence interval. A p value of <0.05 was considered statistically significant.
RESULTS
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The present study was performed on children and adolescents (6 to 18 years old) in Tehran during 2017. Of 2095 individuals, 1077(51.4%) were boy and 1018(48.6%) were girl. The frequency of demographic variables of children and adolescents and their family history of psychiatric disorders and physical illness is shown in Table-1. In this sample, the psychiatric disorders were seen in 328 (30.5%) of boys and 262(25.7%) in girls. The overall prevalence of psychiatric disorders in children and adolescents was 28.2%.The highest percentages of psychiatric disorders in regards with parents’ education were among children of families whose parents had elementary education (38.3%) and their mothers were in the illiterate group (38.8%). The highest rate of psychiatric disorders in regards to parents job was in the group of unemployed fathers (30.8%) and mothers working in private centers (36.6%). The prevalence of psychiatric disorders was not related to those with psychiatric or physical illnesses in their fathers. (Table 2 and 3). Regarding the prevalence of age-related disorders, the highest prevalence was at the age of 17 years (35.7%) and after that was the age of 13 years (33.6%). (Figure 1) The most commonly diagnosed disorders were anxiety disorders (21.9%), followed by behavioral disorders (9.6%), tobacco use (5.5%), and elimination disorders (4.8%). (Figure2) Among the most common anxiety disorders, the most common subgroups were
specific phobias (9.9%), obsessive compulsive disorder (7.8%) and separation anxiety disorder (6.9%), respectively. In the subgroup of behavioral disorders, the most common disorders are attention deficit hyperactivity disorder with 85 cases (4.4%) and oppositional defiant disorder with 76 cases (3.9%), respectively (Table4 and figure 3). According to the findings, mood disorders and anxiety disorders had the highest
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comorbidity with the other psychiatric disorders. (Table5).
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Discussion:
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In this study, the prevalence of psychiatric disorders among children and adolescents in Tehran was studied. The largest number of participants in this study resided in urban areas. The prevalence of psychiatric disorders among children and adolescents in Tehran in our survey was 28.2 (95%CI: 26.28 to 30.12). The prevalence of disorders in the same study in Tehran at 2013 was 14.2%, while the rate in our study is about 2 times. Another study in Tehran at 2010 reported the prevalence about 17.9%, which in total, shows a clear increasing trend in psychiatric disorders in recent years in Tehran.
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The sharp increase in the prevalence of psychiatric disorders over the last few years in Tehran could be due to rapid cultural change) such as the expansion of the media and the rapidly changing cultural outcomes) and a large expansion of urbanization, and also due to socio-economic changes )such as the economic difficulties and the social consequences of it) in the people's situation, which, in turn, will lead to an aggravation of psychiatric disorder.
A
Due to Noorbala et. al. ‘s study about the psychosocial stress in Tehran at 2017, 82.7% experienced at least 1 severe stress during the past year and they emphasized the necessity to take actions to reduce the prevalence of common severe stresses in Tehran. Noorbala et al. evaluated mental health changes among population aged 15 and above in Tehran during 16 years (between 1999 and 2015) and the results of this study showed that about one third of their sample population were supposed to suffer
from a mental disorder at 2015 and reported that the prevalence of common mental disorders has increased from 21.2% in 1999 to 31.7% in 2015.(Noorbala, Yazdi et al. 2017)They strongly recommended that public health authorities put more effort to ensure necessary requirements encompassing prevention and promotion of mental health of the Iranian population residing in Tehran province.
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In our study the overall prevalence of psychiatric disorders in Tehran children and adolescents was 28.2% compared with the two other studies in Tehran at 2008 and 2010 with 14.2% and 17.9% which indicates an increase of 1.9 and 1.6 equal to the two studies, which requires careful consideration of the aesthetics of this issue and the follow-up of prevention and control methods for the causes that affect this prevalence, by policy Mental Health Issues.
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Seyfe Hashemi et al. investigated the prevalence of mental health problems in children(6 to 12 years old) and reported average problem in urban population of Semnan (a nearby province of Tehran) as 19.3% at 2012 .(Hashemi, Yarian et al. 2015) That was lower than our study in Tehran(28.2%), which could be due to the difference in economic-social conditions existing between these two provinces, cultural conditions, the existence of demographic dispersion and the extent of environmental stressors in these two provinces of Iran.
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In similar study in China (Xiaoli, Chao et al. 2014) the prevalence of psychiatric disorders among children and adolescents was about 9.49, which is clearly less than the prevalence earned in our study but the highest number of psychiatric disorders seen as the anxiety disorder is the same in this study and our study. This indicates an outbreak of anxiety disorders among children, regardless of the overall prevalence of psychiatric disorders in this age group. In all above studies, like ours, depression disorders, ODD and ADHD were at a later rank. This may show the similar pattern of psychiatric disorders among children and adolescents regardless of ethnicity and culture.
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Anxiety disorders are among the most common psychiatric disorders among children and adolescents. The prevalence of these disorders is different among children and adolescents, according to age and diagnostic tools. These disorders affect 10% to 20% of children and adolescents, and the incidence of life expectancy in children and adolescents is 10% to 27% .(Benjamin James Sadock 2014)
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In our study, the prevalence of these disorders was 21.9%, which represents the highest expected level among psychiatric patients in this age range, and requires a serious attention in identifying cases with preventive and therapeutic interventions. Creswell et al., presenting that the anxiety disorders are associated with other psychiatric disorders throughout life, emphasized the high prevalence of these disorders.(Creswell, Waite et al. 2014)
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Mishra et al. reported an increase in anxiety disorders in the Eastern Uttar Pradesh in India by 15%. They reported an increased prevalence of these disorders in middle adolescent period and lower socioeconomic groups. (Mishra, Srivastava et al. 2018) Mohapatra et al., In 2013, reported that anxiety disorders are the most common psychiatric disorders(Mohapatra, Agarwal et al. 2013). Sam Cartwright et al. in 2005, reported prevalence of anxiety disorders , with a handful of epidemiological studies on the prevalence of them in young populations, with a range of 2.6% and 41/2% . Also, they reported that the prevalence of these disorders is more than other disorders such as depression and probably behavioral disorders.(CartwrightHatton, McNicol et al. 2006) They suggested that the reasons for this wide range of anxiety disorders reports be evaluated, focusing on the different methods used to measure.
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Gonzales et al., In 2018, reviewed the psychiatric disorders associated with Internet gambling disorders and pathological video-Game use and noted the correlation between them and anxiety disorders of 92%. They emphasized the closer survey of this correlation.(González-Bueso, Santamaría et al. 2018)
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In our study, the prevalence of anxiety disorders was 21/9 %, which was the most prevalent among psychiatric disorders in children and adolescents. The evaluation of causes, attention to the specific behavioral characteristics of this age group, and the prevention, identification and treatment of cases by health policy programs seems to be much needed. Serinath et al., In 2005, surveyed the prevalence of psychiatric disorders in urban and rural areas in a region of India, of which 12.5% were reported. They described the higher prevalence of disturbances in middle class urban areas. Enuresis, specific phobia and hyperkinetic disorder were reported as the most common disorders.(Srinath, Girimaji et al. 2005)
In a meta-analysis ,in 2014,Malhotra et al. reported the prevalence of psychiatric disorders among children and adolescents in the general population 6/46% and schoolchildren 23/33%.(Malhotra and Patra 2014)
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In the study of Cortina et al., in 2012, the prevalence of mental health problems among children in Africa was studied and the prevalence of 14.3% in the general population, based on clinical diagnostic tools, and 8.8% based on screening questionnaires were reported. This study emphasized the relationship between sociodemographic factors and psychopathology. (Cortina, Sodha et al. 2012)
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As we see in the recent study, part of the high prevalence of psychiatric disorders in our study can be due to the impact of the special sociodemographic factors determinants of our study areas. ( For example, the meaningful more prevalence of psychiatric disorders among children and adolescents whose mother had history of physical illness(p value=0.001)).
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In the study by Fleitlich-Bilyk et al. on the prevalence of child and adolescent psychiatric disorders in southeast Brazil, the overall prevalence of DSMIV disorders was 12.7% (Fleitlich-Bilyk and Goodman 2004)which clearly shows a lower incidence than our study (12.7% versus 28.2%).They estimated that approximately one in eight school-age children in the study area in the southeast of Brazil have psychiatric disorders involving a level of distress or social impairment likely to warrant treatment . This estimation in our study was about 2.25 in eight person that is obviously more than that study.
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In the study by Wichstrom et al. at 2012 in Norway on Prevalence of psychiatric disorders in preschool age children(Wichstrøm, Berg‐Nielsen et al. 2012), they reported that in those with lower economic social status, more emotional and behavioral disorders were seen as we see in our study about the children and adolescent whose father jobs were in the position of “unemployed” and of being in low socioeconomic status. Also they reported that Comorbidity among disorders was common as we received in our study. In our study, in the age group of 13 and 17, there is a two-peak increase in the prevalence of psychiatric disorders (33.6% prevalence at age 13 and 35.7% at age 17). Patricia Cohen et al. point to the relationship between the prevalence of psychiatric disorders with age and gender. They point to the influence of age and
gender on the formulation of specific diagnostic patterns of disorders. They also suggest the potential impact of onset of puberty on aggravating major depression symptom . (Cohen, Cohen et al. 1993)
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In 2010, Merikangas et al. serveyed the lifetime prevalence of mental illness among adolescents. They emphasized the proportion of age with some psychiatric disorders. For example, the average age of the onset of mood disorders was 13 years of age and behavioral disorders at the age of 11 years. (Merikangas, He et al. 2010) Loeber et al., also emphasized the influence of age and gender as effective factors on pattern of comorbidity with conduct disorder.(Loeber and Keenan 1994)
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The reason for the existence of two age peak on psychiatric disorders in our study can be attributed to the intensification of the puberty process in this age group among girls (13 years) (Razzaghy-Azar, Moghimi et al. 2006) and boys (17 years) (Ahmadi, Anoosheh et al. 2009) and it’s effect on the mental health status of adolescents and their outcomes.
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Also, the stress of participating in the general entrance exam in governmental and nongovernmental universities in Iran, which is held in the last year of high school, and the results of this stress on increased prevalence of psychiatric disorders, can be due to the increase disturbances in this peak age. (Yousefi, Talib et al. 2010)
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Conclusion: According to the results, more than a quarter (28.2%) of the children and adolescents in Tehran province had psychiatric disorders that is with increasing rate compared with similar studies conducted in Tehran at 2008 (14.2% ) in adolescents and at 2010(17.9%) in children. Therefore, as a public health policy, the necessary tools for identifying, preventing and treating psychiatric disorders in children and adolescents should be considered in Tehran.
Limitations This study is one of the most comprehensive epidemiological studies to investigate the prevalence of psychiatric disorders in Tehran's children and adolescents in different districts of the capital of Tehran. In order to obtain accurate information on the prevalence of psychiatric disorders in children and adolescents throughout the province
of Tehran, it is possible to evaluate the prevalence of these disorders in all cities of the province.
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Conflict of Interest No conflict of interest.
Ethics
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The national institute for medical research development (NIMAD) supported this study (the ethics code of IR.NIMAD.REC.1395.001). Consent was obtained from children and adolescents (Consent was completed for participants younger than 15 years by their parents and for participants aged 15 to 18 years by parents or by the adolescents themselves.). Information about children and adolescents and their families was kept confidential. If children or adolescents were diagnosed with a psychiatric disorder, the child and adolescent psychiatrist, who collaborated on the IRCAP project, treated them out of charge. However, if the participants or their parents did not wish to use the free treatment, then, they were referred to other child and adolescent psychiatrists
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Funding
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This work was supported by the National Institute for Medical Research Development (NIMAD) (Grant No. 940906)
Acknowledgements
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We would like to thank all the families and the children who participated for their cooperation. We also thank the National Institute for Medical Research Development (NIMAD) (Grant No. 940906) and the Psychiatry and Psychology Research Center, Tehran University of Medical Sciences for their financial and non-financial supports. Furthermore, we would like to thank all the interviewers involved in the project.
References
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Alavi, A., et al. (2010). "Frequency of psychological disorders amongst children in urban areas of Tehran." Iranian Journal of Psychiatry 5(2): 55. Benjamin James Sadock, V. A. S., Pedro Ruiz (2014). Synopsis of Psychiatry. New York.
Bilenberg, N., et al. (2005). "The prevalence of child‐psychiatric disorders among 8–9‐year‐old children in Danish mainstream schools." Acta Psychiatrica Scandinavica 111(1): 59-67.
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Cartwright-Hatton, S., et al. (2006). "Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children." Clinical psychology review 26(7): 817-833.
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Cohen, P., et al. (1993). "An epidemiological study of disorders in late childhood and adolescence—I. Age‐and gender‐specific prevalence." Journal of child psychology and psychiatry 34(6): 851-867.
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Cortina, M. A., et al. (2012). "Prevalence of child mental health problems in sub-Saharan Africa: a systematic review." Archives of pediatrics & adolescent medicine 166(3): 276-281.
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Creswell, C., et al. (2014). "Assessment and management of anxiety disorders in children and adolescents." Archives of disease in childhood: archdischild-2013-303768. to
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Ford, T., et al. (2003). "The British child and adolescent mental health survey 1999: the prevalence of DSM-IV disorders." Journal of the American Academy of Child & Adolescent Psychiatry 42(10): 12031211.
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Georgiades, K., et al. (2018). "Prevalence of Mental Disorder and Service Use by Immigrant Generation and Race/Ethnicity Among US Adolescents." Journal of the American Academy of Child & Adolescent Psychiatry 57(4): 280-287. e282. Ghanizadeh, A. (2008). "ADHD, bruxism and psychiatric disorders: does bruxism increase the chance of a comorbid psychiatric disorder in children with ADHD and their parents?" Sleep and Breathing 12(4): 375380.
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González-Bueso, V., et al. (2018). "Association between internet gaming disorder or pathological videogame use and comorbid psychopathology: a comprehensive review." International journal of environmental research and public health 15(4): 668.
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Hashemi, M. S., et al. (2015). "Prevalence of mental health problems in children and its associated sociofamilial factors in urban population of Semnan, Iran (2012)." Iranian journal of pediatrics 25(2): :e 175.
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Kaufman, J., et al. (1997). "Schedule for affective disorders and schizophrenia for school-age childrenpresent and lifetime version (K-SADS-PL): initial reliability and validity data." Journal of the American Academy of Child & Adolescent Psychiatry 36(7): 980-988.
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Kieling, C., et al. (2011). "Child and adolescent mental health worldwide: evidence for action." The Lancet 378(9801): 1515-1525.
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Loeber, R. and K. Keenan (1994). "Interaction between conduct disorder and its comorbid conditions: Effects of age and gender." Clinical psychology review 14(6): 497-523.
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Malhotra, S. and B. N. Patra (2014). "Prevalence of child and adolescent psychiatric disorders in India: a systematic review and meta-analysis." Child and adolescent psychiatry and mental health 8(1): 22.
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Merikangas, K. R., et al. (2010). "Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A)." Journal of the American Academy of Child & Adolescent Psychiatry 49(10): 980-989. Mishra, S. K., et al. (2018). "Prevalence of depression and anxiety among children in rural and suburban areas of Eastern Uttar Pradesh: A cross-sectional study." Journal of family medicine and primary care 7(1): 21.
Mohammadi, M. R., et al. (2017). "Epidemiology of Psychiatric Disorders in Iranian Children and Adolescents (IRCAP) and Its Relationship with Social Capital, Life Style and Parents' Personality Disorders: Study Protocol." Iranian Journal of Psychiatry 12(1): 66.
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Mohammadi, M. R., et al. (2016). "Psychiatric disorders in Iranian children and adolescents." Iranian Journal of Psychiatry 11(2): 87. Mohammadi, M. R., et al. (2013). "Psychological problems in Iranian adolescents: application of the self report form of strengths and difficulties questionnaire." Iranian Journal of Psychiatry 8(4): 152. Mohapatra, S., et al. (2013). "Pediatric anxiety disorders." Asian journal of psychiatry 6(5): 356-363.
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Polanczyk, G. V., et al. (2003). "Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E)." Revista Brasileira de Psiquiatria 25(2): 87-90.
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Razzaghy-Azar, M., et al. (2006). "Age of puberty in Iranian girls living in Tehran." Annals of Human Biology 33(5-6): 628-633.
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Shahrivar, Z., et al. (2008). "Prevalence of psychiatric disorders amongst adolescents in Tehran." Iranian Journal of Psychiatry 3(3): 100-104.
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Srinath, S., et al. (2005). "Epidemiological study of child & adolescent psychiatric disorders in urban & rural areas of Bangalore, India." Indian Journal of Medical Research 122(1): 67.
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Wichstrøm, L., et al. (2012). "Prevalence of psychiatric disorders in preschoolers." Journal of Child Psychology and Psychiatry 53(6): 695-705. Wu, J., et al. (2016). "Parent-reported Mental Health Problems and Mental Health Services Use in South Australian School-aged Children." AIMS public health 3(4): 750. Xiaoli, Y., et al. (2014). "Prevalence of psychiatric disorders among children and adolescents in northeast China." PLoS One 9(10): e111223.
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Yousefi, F., et al. (2010). "The relationship between test-anxiety and academic achievement among Iranian adolescents." Asian Social Science 6(5): 100.
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This work was supported by the National Institute for Medical Research Development (NIMAD) (Grant No. 940906)
PREVALENCE OF CHILD AND ADOLESCENTS PSYCHIATRIC DISORDER IN TEHRAN PROVENIENCE 9.9 7.8
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6.9
5.5 5.2 4.7 4.4 3.9
N
A
0.7 0.7 0.6 0.4 0.4 0.3 0.3 0.3 0.2 0.2 0.1 0.1
U
2.8 2.8 2.3 1.9 1.9
TE
D
M
SPECIFIC PHOBIAS OBSESSIVE COMPULSIVE DISORDER SEPARATION ANXIETY DISORDER TOBACCO USE AGORAPHOBIA ENURESIS ATTENTION DEFICIT HYPERACTIVITY DISORDER OPPOSITIONAL DEFIANT DISORDER TIC DISORDER GENERALIZED ANXIETY DEPRESSIVE DISORDERS EPILEPSY SOCIAL PHOBIA CONDUCT DISORDER HYPOMANIA MENTAL RETARDATION POST-TRAUMATIC STRESS DISORDER MANIA BULIMIA NERVOSA AUTISM PSYCHOSIS ALCOHOL ABUSE PANIC DISORDER ANOREXIA NERVOSA ENCOPRESIS
0
2
4
6
8
10
A
CC
EP
Figure 1: Prevalence of psychiatric disorders in children and adolescents Tehran provenience
12
ALCOHOL ABUSE
0.2
EATING DISORDERS
0.3
PSYCHOSIS
0.3
NEURODEVELOPMENTAL DISORDERS
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CHART TITLE
2.5
MOOD DISORDERS
2.8
ELIMINATION DISORDERS
4.8
TOBACCO USE
5.5
BEHAVIORAL DISORDERS
U
9.6
5
10
21.9 15
20
25
A
0
N
ANXIETY DISORDERS
TE
D
M
Figure 2: Prevalence of psychiatric disorders in children and adolescents Tehran provenience
EP
29.2
27.4
33.6 31
28.3
30 28
27.8 26.1
27
CC
26.9
35.7
A
20.2
6
7
8
9
10
11
12
13
14
15
16
17
18
A
CC
EP
TE
D
M
A
N
U
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Figure 3: prevalence of child and adolescents psychiatric disorder by age tends
Demographic variables
place of residence Father education
A
M
D
Father job
TE
Mother job
Father history of psychiatric disorder Mother history of psychiatric disorder Father history of physical illness Mother history of physical illness Total
EP Health variables
CC A
Percent 51.4 48.6
781 843 471 2083 12 38 175
37.3 40.2 22.5 99.4 .6 2.0 9.0
365
18.8
714 456 193
154 49 161
2.5 8.2
13.7
864 511 116
43.8 25.9 5.9
123
Public sector Private sector unemployed
685 1227 39
Missing
144
Public sector Private sector
268 82 1629
unemployed (Housewife) Missing Yes No Missing Yes No Missing Yes No Missing Yes No Missing
36.8 23.5 9.9
271
N
Mother education
n 1077 1018
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Age
Boy Girl 6-9 10-14 15-18 Urban Rural Illiterate primary school Guidance or high school Diploma bachelor MSc or higher Missing Illiterate primary school Guidance or high school Diploma bachelor MSc or higher Missing
U
Sex
35.1 62.9 2.0 13.5 4.1 82.3
116 2076 18
99.1 .9
1 2064 29
98.6 1.4
2 1845 212
89.7 10.3
38 1802 252
87.7 12.3
41 2095
100
Table 1: Frequency of Demographic Variables in Children and Adolescents (6-18) of Tehran provenience
Variables
32.6
200 116
28 25.4
50
25.9
26 19
38.8
52
32.3
91
Father history of psychiatric disorder Mother history of psychiatric disorder Father history of physical illness
8.829
0.116
31.81 31.7 46.42
0.199
0.905
2.726
0.256
0.001
0.970
0.575
0.448
30.06 34.22
0.002
0.966
28.5
12.146
0.001
45.67 37.57 31.41 29.63 32.52
26.43 25.56
52.76
33.6
28.22
39.4
28.7 25.6
25.78 22.05 20.27
31.81 29.6
32
27.6
39.86
36.34
123
22.26 26.98
32.86 47.4
469
28.8
26.64
31.04
18 585
28.2
26.29
30.15
No
5
27.8
12.5
50.87
Yes
580
28.1
26.2 19.94
30.08
No
10
34.5
Yes No
516 59
28 27.8
Missing
15
Yes
476
EP A
CC
Mother jobs
unemployed (Housewife) Missing Yes
0.163
0.017
27.2 36.6
Missing
3.626
13.778
25.07 26.63 18.57
Public sector Private sector
0.016
154
248 131
17 194 357 12 27 73 30
24.84 21.66 20.24
5.759
0.690
28.3 29.1 30.8
TE
Father jobs
Public sector Private sector unemployed
27.99
Sig
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119
D
Mother educations
38.3
Chi Sq.
0.160
U
Father educations
67
31.41
N
place of residence
CI (95%) min max 27.78 33.26 23.15 28.51 22.80 28.92 26.67 32.83 25.57 33.78 26.24 30.1 13.81 60.93 19.09 47.46
A
Age
Boy Girl 6-9 10-14 15-18 Urban Rural Illiterate primary school Guidance & high school Diploma bachelor MSc or higher Missing Illiterate primary school Guidance & high school Diploma bachelor MSc or higher Missing
M
Sex
with disorder n percent 328 30.5 262 25.7 201 25.7 250 29.7 139 29.5 586 28.1 4 33.3 12 31.6
144
116
52.65 25.97 22.23
38 26.4
24.44
Mother history of physical illness
No
93
31.18
36.9
43.01
41 Missing Total
21 590
28.2
26.28
30.12
A
CC
EP
TE
D
M
A
N
U
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Table 2: Prevalence of Psychiatric Disorders in sample of Tehran provenience in Terms of Demographic
P-value
OR (adjusted)
CI (95%)
P-value
female
0.79
0.65-0.96
0.017
0.81
0.67-0.99
0.043
6-9 10-14
1.00 Baseline 1.22
0.98-1.51
0.078
1.120
0.89-1.41
0.33
15-18
1.21
0.94-1.56
0.146
1.092
0.84-1.43
0.52
Urban
1.00 Baseline
0.769
0.52-1.14
0.19
0.643
0.43-0.96
0.031
High school
0.82
0.58-1.17
0.273
Diploma
0.66
0.48-0.91
0.012
bachelor
0.58
0.41-0.82
0.002
0.526
0.33-0.84
0.008
MSc or higher
0.59
0.39-0.91
0.016
0.29-0.92
0.024
Illiterate & primary school
1.00 Baseline
N
0.515
High school
0.99
0.68-1.45
0.96
1.132
0.74-1.72
0.57
Diploma
0.79
0.57-1.09
0.15
1.008
0.67-1.51
0.97
Bachelor
0.68
0.48-0.96
0.027
0.984
0.61-1.58
0.95
Msc or higher
D
0.45-1.23
0.25
0.949
0.49-1.84
0.88
0.84-1.28 0.56-2.26
0.72 0.74
0.833 0.901
0.65-1.06 0.43-1.89
0.14 0.78
0.91-2.60 0.81-1.44
0.11 0.61
1.493 0.931
0.85-2.62 0.66-1.32
0.16 0.69
0.35-2.76
0.97
0.97
0.30-3.16
0.96
0.62-2.91
0.45
1.24
0.52-2.95
0.62
0.72-1.36
0.96
0.95
0.68-1.32
0.76
1.24-2.15
0.001
1.64
1.23-2.17
0.001
M
TE
0.75
Public sector
Private sector unemployed Public sector
A
CC
Private sector Unemployed (Housewife) Father history of no psychiatric disorder yes Mother history of no psychiatric disorder yes Father history of no physical illness yes Mother history of no physical illness yes
OR adjusted: Odds Ratio CI: Confidence Interval
1.00 Baseline 1.04 1.13 1.00 Baseline 1.54 1.08 1.00 Baseline 0.98 1.00 Baseline 1.35 1.00 Baseline 0.99 1.00 Baseline 1.63
U
1.00 Baseline
A
Illiterate & primary school
EP
Locus of life Father education Mother education Mother job
Father job
Demographic variables Health variables
Rural
SC RI PT
OR (crude) 1.00 Baseline
CI (95%)
male
Age group
Sex
Variables and their categories
A
CC
EP
TE
D
M
A
N
U
SC RI PT
Table 3. Odds Ratios (95% CI) for total psychiatric disorder in term of demographic and health variables
Confidence Interval
Psychiatric Disorders
Mania Hypomania Total Mood Disorders Psychosis
8 14 54 5
Panic Disorder Separation Anxiety Disorder Social Phobia Specific Phobias Agoraphobia Generalized Anxiety Obsessive Compulsive Disorder Post-Traumatic Stress Disorder Total Anxiety Disorders Attention Deficit Hyperactivity Disorder Oppositional Defiant Disorder Conduct Disorder Tic Disorder Total Behavioral Disorders Autism Mental retardation Epilepsy
3 135
M
D
TE
Neurodevelopm ental disorders
Total Neurodevelopmental disorders
CC
EP
Substance abuse disorders
A
Elimination Disorders
Eating Disorders
Total
Tobacco use Alcohol abuse Drug abuse Total Substance abuse disorders Enuresis Encopresis Total Elimination Disorders Anorexia Nervosa Bulimia Nervosa Total Eating Disorders
Min
Max
1.76
3.13
0.4 0.7 2.8 0.3
0.2 0.4 2.2 0.1
0.8 1.2 3.6 0.6
0.2 6.9
0.05 5.88
0.4 8.13
1.9 9.9 5.2 2.8 7.8
1.37 8.69 4.27 2.12 6.66
2.57 11.35 6.24 3.58 9.03
0.4
0.2
0.8
411 85
21.9 4.4
20.04 3.55
23.77 5.37
76
3.9
3.1
4.82
14 55 185
0.7 2.8 9.6
0.4 2.16 8.36
1.2 3.63 11
6 13 40 48
0.3 0.6 1.9 2.5
0.14 0.36 1.41 1.85
0.67 1.06 2.59 3.23
116 4
5.5 0.2
4.64 0.09
6.6 0.6
117
5.6
4.68
6.65
93 1 94
4.7 0.1 4.8
3.88 0.01 3.93
5.76 0.3 5.83
1 5 6
0.1 0.3 0.3
0.01 0.12 0.15
0.03 0.63 0.7
590
28.2
26.66
30.56
37 194 101 54 152 8
A
Behavioral Disorders
percent 2.3
SC RI PT
Anxiety Disorders
Number 45
U
Psychotic Disorders
Depressive Disorders
N
Mood Disorders
Table4: Prevalence and Confidence Interval of Psychiatric Disorders in the Tehran provenience children and adolescents (6-18)
Eating Disorders F(P)
Elimination Disorders F(P)
Substance abuse disorders F(P)
Neurodevelopm ental disorders F(P)
Behavioral Disorders F(P)
Anxiety Disorders F(P)
Psychotic Disorders F (P)
1(1.9)
3(5.6)
8(21.6)
2(3.7)
18(36)
32(66.7)
5(9.3)
0
0
0
0
3(60)
4(80)
5(1.3)
33(8.1)
23(6.8)
12(3)
81(20.1)
0
21(11.5)
19(13.5)
11(6)
0
5(11.6)
2(5.6)
1(0.9)
12(10.5)
3(1.6)
18(10.2)
11(26.8)
12(30)
0
2(4.8)
2(1.8)
19(17.3)
23(21.7)
0
8(7.3)
12(14.6)
5(5.4)
21(24.4)
33(37.9)
0
3(3.4)
1(33.3)
0
0
5(83.3)
0
1(16.7)
A M D TE EP CC
Psychotic Disorders
SC RI PT
81(46.6)
Table 5: Comorbidity disorders according to the type of psychiatric disorder in the Tehran provenience
A
Main disorder
5(100) 32(8.1)
N
1(16.7)
Comorbid disorder
Mood Disorders
4(1)
U
1(1.1)
Mood Disorders F (P)
Anxiety Disorders Behavioral Disorders Neurodevelopme ntal disorders Substance abuse disorders Elimination Disorders Eating Disorders