J . Child PsychoL Psychiat., Vol. 18, 1977, pp. 23 to 37. Pergamon Press. Printed in Creat Britain.
CHILDREN IN UGANDA: RATES OE BEHAVIOURAL DEVIATIONS AND PSYCHIATRIC DISORDERS IN VARIOUS SCHOOL AND CLINIC POPULATIONS KLAUS K . MINDE*
Department of Psychiatry, The Hospital for Sick Children, University of Toronto INTRODUCTION COMPARATIVE estimates of the prevalence and types of psychiatric disorders in different cultures are of importance in delineating the degree to which such disorders are culture bound in their general manifestations. Yet there are many difficulties in pro\'iding reliable data on mental disorders for African countries because these countries are frequently neither an ethnic nor a cultural entity but consist of a multitude of distinct cultures. One further major problem is that psychiatric research reports from Africa have almost exclusively been offered by European psychiatrists who have an unavoidable ethnocentric bias. African researchers have nearly all been trained in Europe and the U.S.A. and have not yet developed an indigenous African school of psychiatry. Moreover, research techniques developed in the industrialized nations do not always fit the African situation since populations are often illiterate, family names non-existent and demographic statistics are unavailable. Despite these severe limitations recent work has been carried out and indicates that the incidence of psychiatric illness in new adult outpatients coming to a small general hospital in Uganda (German, 1972) or Ethiopia (Giel and Van Luijk, 1969) and a semi-rural clinic in Nigeria (Mbanefo, 1971) is about 15-20%. Leighton et al. (1966) visited 15 villages and a small city in Western Nigeria and counted the psychiatric symptoms of 326 men and women. Of all adults examined 40-45% were found to show psychiatric impairment (pp. 124-137). Work with children has been much more impressionistic. Izuora (1970) and Asuni (1970) described a mental health clinic in Enugu and Eagos respectively but gave only a very general description of their patients, citing their age, sex, and diagnosis. Goodall (1972) described seven particular cases attending a general paediatric outpatient clinic in Kampala but gave no indication of the rate of emotional disorders among her clinic population. Rahim (1972) reviewed the clinical diagnoses of 319 children seen in Port Sudan over a 6 yr period but did not specify the criteria used in arriving at his diagnostic categories. Okasha et al. (1972) described the symptomatology of 134 depressed children seen in Cairo over a 3 yr period. The authors differentiated between children with phobic depression, enuretic
•Address for reprints: Department of Psychiatry, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Ontario, Canada. 23
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KLAUS K. MINDE
and manic depression and those labelled "depressives". The symptoms leading to their respective diagnoses such as "difficulties at school", "immaturity", "lack of confidence", "warm personality", were not operationally defined and hence cannot be replicated. Giel et al. (1969) went beyond the case description of patient samples and studied the psychiatric morbidity of two Ethiopian villages. They found that 3-4% of all children under the age of 9 and 10% of those 10 yr and older showed psychological abnormalities. No detailed breakdown of symptomatology was given. The author, in previous publications (Minde, 1974, 1975), has examined the incidence and treatment of psychiatric difficulties in various child populations in Uganda more systematically, and found the global incidence of psychiatric disturbance in primary school children to be 18% with a high rate of 24% in an urban setting and 10-5% in a rural area. A single study, by Cederblad (1968), focused on specific psychological symptoms in children. She screened all 1716 children aged 3-15 who lived in a Sudanese village of about 5000 with respect to stuttering, sleep walking, enuresis, encopresis and sleep disturbances. Children showing more than one of the above symptoms and a Swedish control group were then studied in more detail [N = 197). Gederblad found the Sudanese children to have a generally lower rate of severe symptoms than those ofthe Swedish sample (8 vs 25%). The Sudanese, however, showed a higher incidence of aggression and nocturnal enuresis than their Swedish controls. There are, however, a number of problems with the study. The questionnaire used in Cederblad's study has not been documented to contain items primarily denoting psychopathology. In fact, many ofthe items differentiating the European and African sample (e.g. enuresis, sleep disturbance), are of questionable psychiatric significance. The interviews were performed by medical students unfamiliar with psychiatric phenomenology and interview techniques. They were also often held in the presence of neighbours and other onlookers. These factors may have reduced the reliability of results. No attempts were made to validate the mothers' behavioural observations by others familiar with the children, such as teachers or other relatives. In summary, the African literature provides increasing evidence that a number of African children suffer from psychological disorders and are given diagnostic labels originally created to describe European children. It is not known whether these labels give an adequate picture ofthe disturbance as it is perceived by Africans themselves and whether the symptoms which contribute to making a particular psychiatric diagnosis are comparable in Africa and Europe. Furthermore, it is not known whether English questionnaires with their abstract description of individual behaviours can be translated into a Bantu language which in its structure favours detailed descriptions of events over words noting abstract concepts. Finally it is not known whether any psychiatric disorders of African children described by their parents are also reported by their teachers. The present investigation attempts to fill these gaps. METHOD Setting
Uganda, situated in East Africa, straddles the Equator and is about the size of Great Britain. The country has been independent since 1962 and is populated by various tribal groups who speak differ-
CHILDREN IN UGANDA
25
ent languages and have attained various levels of education and economic sophistication. While the northern parts have distinct dry and rainy seasons, the south gets evenly spaced rain, making it one ofthe most fertile regions in the whole of Africa. Coffee, tea and cotton provide the bulk ofthe cash income for the country's ten million inhabitants. The present study includes only children living in Buganda, the most developed province in the south of the country where people speak one common language and primary school attendance has reached about 50%. This allowed us to work in one language and within one cultural eontext. Subjects (a) Primary schools. All children attending grades 2-7 aged 7-15 in three primary schools participated in the study (N — 577). School I was situated in a remote rural area with no medical and very poor academic facilities. The school building was made out of mud and one class was instructed under a tree as its room had collapsed. There were only 20 pencils for the lower four grades and one book per classroom. Teachers were poorly trained. All people in the area lived on subsistence farming. School II was 35 miles north ofthe capital in a fertile rural district, had semi-permanent structures, well trained teachers and an excellent Maternal and Child Health Centre nearby. The population in the area farmed but some had established contacts with hotels or other institutions in the capital and sold their produce regularly. School III was in the capital and frequented by lower middle-class African children. The school had the best equipment of all three institutions and at times even teachers trained in specialties such as science and music. The children's parents worked in lower government positions or were tradesmen. (b) Reform school. M\ primary school age youngsters (15 yr and under) committed by various courts to the only reform school in Uganda participated in this study {N = 68). Ihis group WM divided into those cliildren committed for delinquent offences (delinquent chiidren, N = 48) and those admitted as "care and protection" cases (neglected children, N — 20). The school had only boys. (c) Outpatient clinic. All children aged 6-15 attending a child psychiatric outpatient clinic for the first time within a 6 month period were included in the study (N ~ 61). Procedure
The research strategy was based on a two-stage procedure. Initially the teachers of all children in the primary and reform schools were asked to complete a symptom screening test developed by Rutter (1967) Children whose scores suggested the presence of a psychiatric disorder were matched on sex and age with controls and then interviewed more intensively. Their parents were also visited and given a semi-structured interview, using the Peterson-Quay Symptom Check List (1967) as a symptom inventory. The latter Symptom Check List was used because the author at the time ofthe research planning did not know of the existence of the parental symptom screening instrument developed by Rutter et al. (1970). Both scales were used because they had been factor analyzed for children of similar ages, had been used in a number of investigations assessing British (Rutter et aL, 1970) and West Indian children (Rutter et al.., 1974) and were familiar to the author. After both family and child had been interviewed clinically by tbe author, but before tbe individual factor scores of the teacher and parental scales were computed, the author assigned a clinical diagnosis to each child, using the GAP classification (1966). This classification is widely used in North America, has been shown to be applicable to other cultures (Nurcombe and Cawte, 1967) and was familiar to the author. .Ml outpatients attending the child psychiatric clinic for the first time were screened elinically and divided into those presenting with severe organic handicaps and those with bebavioural abnormalities. Only the latter group was investigated in more detail. (a) Screening procedures. Rutter's teacher's questionnaire, which asked teachers to rate each child in his/her class on 26 specific behaviours, was used as the primary screening instrument in the public and reform schools. The questionnaire requires ihe teacher to note whether any of the stated behaviours "does not apply", "applies somewhat" or "very much". This questionnaire was translated into Luganda, the indigenous language of the province all children and their teachers came from. The translation was done by one graduate social worker who had done part of his training in the
26
KLAUS K. MINDE
U.K. and one psychologist who had obtained her M.A. in the U.S.A. As Luganda often does not have single word equivalents for the more abstract concepts asked for in the questionnaire (e.g. question 3, "squirmy child", in Luganda reads—"moving tbe limbs pretty fast in a funny way like the Konga monkey"), the questions were retranslated into English by another person. This provided a check on tbe clinical specificity ofthe questions. In addition, the questionnaire was presented to three primary school teachers, one of whom had trained in Ireland, to assess the relevance ofthe itenns for a school situation. All the items were felt to be potentially observable in a school situation but they were generally not considered to be part of a normal Ugandan school child's behavioural repertoire. The outpatient clinic screening was done by an assistant who also functioned as an interpreter. The assistant enquired about the age of the child and parents, parental occupation, and the type of house tbey lived in. He also noted age of siblings, the type of family the child lived in, the number of moves he bad in his life, his developmental milestones, as well as previous medical and school history. All those children presenting with severe developmental delays and/or a history indicatii^ cerebral insults, including epileptic seizures, were excluded from further study. (b) Individual examinations. Each child with an abnormal score (9 or more) on the teacher's questionnaire were selected for a possible furtber study. This included a previously described interview with the child (Minde, 1975) and a 1-2 hr home visit during whicb specific background and developmental data were obtained. In addition, each parent was given the Peterson-Quay Symptom Check List (1967). This check list requires the adult to indicate wtiether 55 specific behaviours "never occur", "sometimes occur", or "often occur". Tbe questionnaire was translated into Luganda and each question read to the parents by an assistant in the presence of the author. Following the interview the author assigned a clinical diagnosis to each child, using tbe GAP classification (1966). Out of the total of 577 primary school children 105 scored within the abnormal range on the teachers' questionnaire. As time did not permit studying them all, the two to three children with the highest score in each primary class were selected for furtber study and matched with a classmate of the same sex and age whose score was amongst the lowest. A total of 48 problem and 48 control children, representing extreme scores on either end, were evaluated. The reform school had 68 children in tbeir junior section who attended scbool witbhi the institution. Of these, 48 had been committed because of deliquent acts and 20 because of severe parental neglect. Forty-six of the 48 delinquent children scored 9 and bigher on the teacher's questionnaire whereas only 10 out of the 20 neglected cbildren did so. Only 3! of tbe total group were bom in Buganda, the others came from nine other tribes. Yet all children had been at tbe institution for at least six months and were conversing in the local language. Two teachers did not speak Luganda as their mother tongue and rated the children on tbe English version ofthe teacher questionnaire. Half of the higb scoring delinquent children and each neglected child was studied in detail (23 vs 20 cbildren). Tbe housemaster of each reform school child filled in the Peterson-Quay Symptom Check List in place ofthe parent. A total of 61 children aged 6-15 presented to the outpatient clinic. Of these 27 had primary behaviour disorders and were evaluated further. Only 13 of these 27 children attended school. As these children all came from different schools many miles apart the teacher's questionnaire could not be used in this population. The home visit was also replaced by an interview at the clinic where tbe parent was given the Peterson-Quay Symptom Check List by the author.
RESULTS
Table 1 indicates that age differs significantly only between the reform school boys and those in the clinic and school populations. The reform school boys were significantly older {t = 4-56, d.f. -= 94,/» < 0-01). The social class of the children was assessed using a modification of the five classes delineated by Hollingshead (1958). The classes were as follows: Class 1: Professionals with university education; Class 2: senior government officials and owners of large businesses who had secondary school education up to
CHILDREN IN UGANDA TABLE 1. AGE
mean s.d. N
School Problem Control Boys Girls Boys Girls 11 -2 12-2 10-9 12-1 2-4 18 2-5 2-0 30 18 30 18
27
(yr) Clinic Boys 10-4 3-1 18
Girls 10-6 3-0 9
Reform school Delinquent Neglected Boys Boys 13-1 12-9 1-3 17 23 20
S4; Class 3; junior civil servants, primary school teachers, policemen, clerks; Class 4: craftsmen, farmers owning more than three acres, mechanics; Class 5: small plot farmers, unskilled labourers. Table 2 indicates that social class was similar for the various groups. TABLE 2. SOCIO-ECONOMIC CLASS
I + II
III
IV f V
2 5 5
11 8 6 5 2
34 32 16 16 17
C-I
School problem School control Clinic Reform delinquent Reform neglected
1
X' = 6-97
d.f.^
8 n.s.
Further background data are reported in Table 3. Boys and girls in botli the school and clinic population did not vary in any of the background criteria. Consequently, in subsequent analyses sexes were combined. All groups scoring in the abnormal range on the Rutter scale had significantly more broken homes (x^ = 5-5, ^•/ = ^,P < 0-02, for controls vs problem boys; x^ = B-15, d.f. ^ \,p < 0-01 for' control vs clinic children) than the school controls with the reform school children having an even higher rate of broken homes than the two other patient populations. (X^ = 6-34, d.f. = l,p < 0-02, clinic children vs delinquents.) The presence of past serious medical illnesses and parental death did not differentiate the groups. TABLE 3. BACKGROUND DATA
Broken home 1 parent dead Bad moves Serious medical illness
School Problem Control 39-5 14-5 8-3 104 41-6 12-5 18-7 229 - 48
jV = 48
Clinic (°/ ) 444 18-5 22-2 22-2
Reform del. (%) 73-9 19-5 41-3 19-5
Relbrm neg. (%) 75-0 25-0 50-0 35-0
.V = 27
A" == 46
N ^ 20
\
/a)
Tables 4 and 5 compare the various patient and the school control groups on the two symptom check lists used in the investigation. Table 4 gives the sum totals ofthe various groups. The student /-test revealed no statistical significance between boys and girls in the school and clinic samples. The dehnquents scored significantly higher than their neglected schoolmates on the teacher rating scale {t = 5-53,
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KLAUS K. MINDE
d.f.^A\,p < 0-001), but not on the ratings of their housemasters ( / = 1-29, (/./. = 41, n.i.).'The primary school problem children scored significantly higher than their controls on both the teacher symptom ratings {t = 12-9, d.f = 94, /? < 0-001) and the parent symptom ratings [t = 4-28, d.f = 94, p < 0 - 0 5 ) . TABLE 4. TOTAL SYMPTOM CHECK LIST SCORES
Boys N = SQ Girls j V = 18
mean s.d. mean s.d.
Primary schools Controls
Boys A - = 30 Girls N = 18
mean s.d. mean s.d.
Clinic group
Boys J V = 18 Girls N =9
mean s.d. mean s.d.
Delinquent .M=23 Neglected JV-20
mean s.d. mean s.d.
Primary schools Problems
Reform school
Teachers 15-8 58 14-8 6-7 1-4 19 1-6 17
Parents 17-6 11-1 161
HI 6-4 46 3-2 1-5 13-1 12-6 110 9-3
20-1 7-1 9-8 6-2
33-4 16-8 21-0 23-5
Table 5 compares the primary and reform school population on each item of the teacher's questionnaire. A preliminary analysis comparing both the problem boys and girls of each primary school with those of the other two primary schools revealed only one differentiating item. The city school had significantly more children which were seen as hyperactive by their teachers (Teacher's Questionnaire item No. 1) than both country schools, (x^ = 10-6, d.f. = l,p < 0-05.) The relative homogeneity among the three primary schools permitted a combined analysis. The four groups were compared with each other on each item of the teacher's symptom check list, using the three possible answers to each question (doesn't apply, applies somewhat, applies very much) in a 2 X 3 /^ analysis. To facihtate the reading of the table, however, Table 5 records only the total percentage of children who scored "applies somewhat", and "apphes very much", on each item. Looking first at problem school boys and their controls the table shows that items 12, 13, 21, 23 and 25 do not differentiate between these groups. Only item 14 does not differentiate between controls and reform school delinquents but items 1, 2, 12 13 21, 22, 23, 24 and 25 do not between the controls and the neglected boys at the reform school. The delinquents scored significantly higher than the problem school boys on items 1, 12, 13, 17, 20, 21 and 23 with the school boys scores being higher on item 14. The neglected reform school children scored significantly higher than the problem school youngsters on items 17 and 20 and significantly lower on items 2 and 14.
29
CHILDREN IN UGANDA TABLE 5. COMPARISON OF ITEMS ON TEACHER SYMPTOM CHECK LIST (%)
No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
Individual item Very restless Truants from school Squirmy fidgety child Often destroys own or others belongings Frequently fights with other children Not much liked by other children Often worried Tends to do things on his own Irritable Miserable, unhappy, tearful or distressed Twitches, mannerisms/ticks Sucks thumb/fingers Bites nails/fingers Absent from school Is often disobedient Poor concentration, short attention span Fearful/afraid of new things Fussy/over-particular child Tells lies Has stolen things Has wet/soiled self Complains of aches or pains Tears on arrival at school S tut ters/s tammers Other speech difficulty Bullies other children Total A"
School Reform school Problem Control Delinquent Neglected 43-3 13-3 65-2 35-0 43-3 0-0 41-3 5-0 53-3 3-3 73-9 45-0 40-0 3-3 58-7 35-0 43-3 6-6 60-9 30-0 56-6 0-0 80-4 30-0 53-3 10-0 65-2 70-0 200 53-3 73-9 55-0 633 0-0 76-1 70-0 66-6 10-0 69-6 40-0 23-3 3-3 45-7 40-0 6-6 3-3 34-8 15-0 10-0 66 41-3 20-0 63-3 13-3 34-8 20-0 500 0-0 76-1 30-0 70-0 6-6 71-7 50-0 433 3-3 65-0 78-2 36-6 3-3 60-9 25-0 633 0-0 78-2 45-0 266 0-0 63-0 60-0 33 00 47-8 25-0 50-0 6-6 54-3 25-0 10-0 6-6 41-3 0-0 16-6 3-3 32-6 10-0 3-3 6-6 28-2 25-0 40-0 100 58-7 20-0 30
30
43
20
Following the comparison for each item the factor scores indicating the presence of a neurotic or conduct disorder were determined for each child. These factors had been derived by Rutter et al. (1970) through factor analysis ofthe total scale and took in four items for the neurotic and six items for the conduct disorder. These factor scores were then compared with the neurotic and conduct factor score of the parental symptom check hst. The parental factors had also been arrived at by the originators of this scale (Peterson and Quay, 1967) and out ofthe total of 55 items took in 14 items for the neurotic and 17 for the conduct rating. This factor score comparison between teacher and parent ratings was thought to be more appropriate than an individual item comparison ofthe two scales for a number of reasons. The parental scale had about twice as many items as the teacher's scale, making it rather long for item-by-item presentation. Also, while Rutter et al. have pubUshed their raw data, thus allowing comparison of their data with those of African children in the present study, no such data are available for the North American children used in the Peterson-Quay scale. Table 6 indicates that teachers and natural parents significantly agree on labelling their boys and girls as having a neurotic or conduct disorder. Agreement did
CHILDREN IN UGANDA
31
diagnoses (sociosyntonic behaviour disorder) than all other groups {x^ = 3-49, d.f.= 1, /* < 0-1 vs neglected children and x^ = 5-88, d.f. = \,p < 0-02 vs school boys) and were less often seen as behaviour disorders than the school boys (/^ = 4-56, d.f ^- \,p < 0-05).
To assess the agreement between the psychiatric diagnosis and the parents' and teacher's evaluation, a final analysis was performed which compared the diagnosis given to each problem child with his factor scores on the parental and teacher questionnaire. The results showed that teacher ratings alone did not correspond to the fmal diagnosis made by the author as highly as the parental factor scores. The following pattern emerged. Tiie 18 school children who scored higher on the neurotic than on the conduct factor were diagnosed as either "reactive behaviour disorders" (10 children) or as "developmental deviation; situational stress; neurotic behaviour; or psychosomatic disorder" (8 children). The latter group comprised 80% of children so diagnosed. In all children scoring 10 or higher on the parental conduct factor the clinical diagnosis was "personality disorder" (4 children) or "reactive behaviour disorder" (4 children). In these eight cases the teacher questionnaire also indicated the prevalence of conduct over neurotic items. Among the five delinquent reform school children chnically diagnosed as behaviour disorders three scored higher on the neurotic than on the conduct factor on the parental scale while the other two showed conduct factor ratings under 10. The teachers rated one as neurotic, one as equal and three as conduct disorders. The other 12 children who were diagnosed as personality disorders (tension discharge or sociosyntonic disorder) with only one exception scored above 10 on the parental conduct factor and in 10 instances were rated as conduct disorders by their teachers. DISCUSSION The present study will be discussed both from a methodological and clinical point of view The 166 children examined appeared to be a substantial number. Yet subsample size is small, especially for girls, and makes any generalization ofthe data to other parts of Uganda or Africa hazardous. The results nevertheless bring out a number of interesting facts. Girls are under-represented in both the school and clinic samples. This was not primarily due to selective school attendance, as the enrolment of girls in these schools was close to 45%, but to the smaller number of girls who were seen as behaviourally deviant by their teachers and/or parents. In addition the schoolgirls were somewhat older than the schoolboys. This suggested that disturbing symptoms in girls manifest themselves later than in boys or that they are milder and take longer to identify. The question to what degree school children in a developing country are representative of tlie child population in general is difficult to answer. The author with the help of the local chiefs and others familiar with the local area, unsuccessfully tried to find families in any of the school districts who had never sent a child to school. Each family which was thought to qualify had at least one of their children in school, often on a rotating basis, and would have sent more if their financial situation had allowed it. This would indicate that school children, at least in the
32
KLAUS K. MINDE
districts under study may present a fairly adequate reflection of all children in the population. The socio-economic homogeneity of the total sample is not surprising. The great majority of Africans still live on subsistent farming or have relatively unskilled occupations. Future changes may be reflected in the clinic population where almost 40% of all children came from upper or middle-class homes. Further background data confirmed previous impressions by the author (Minde, 1975). They indicate that children who come from homes which have broken up because of divorce or desertion of one parent are significantly more Ukely to be disturbed and that this is especially evident in children who end up in a reform school. The reform school children, especially those admitted for "care and protection" had in addition lost the support of their extended families. Their life styles were frequently endless repetitions of tragic events rarely encountered even in the most deprived parts of our cities. There were children wandering through the country from age 7 onwards, living off the land, being exploited and mishandled until they were finally picked up by the police and often placed with adult criminals in prison cells. Others stole a bit of food or a shirt as they had not been given any food for days, were caught, beaten and then sentenced to up to three years in a reform school. The disintegration of the families is confirmed by the high percentage of all problem children who had experienced a move which was not in keeping with tribal traditions. This has been discussed in a previous paper {Minde, 1975) and implies that these children had to leave their homes because their families broke up or they were dismissed rather than because an aunt who lived closer to school wanted the child to stay with her. Parental death was most common among the "neglected" group but did not differentiate the problem from the control school children. This lends support to a recent study by Rutter (1971) which shows that the death of a parent is less traumatic for British children than parental quarrels. The use of a rating scale devised for European children in an African setting was naturally approached with a good deal of initial hesitation by the author. However, after assessing a good number of children in the outpatient cHnic and on paediatric wards and after discussion with a number of African medical colleagues, he did feel that at least some behaviours were considered abnormal in both cultures. The item analysis ofthe teacher symptom check list lends support to this impression in that only 20% of all items did not diflferentiate between control, problem school, and neglected reform school children. These items were mainly indicating habit disorders (e.g. nail biting, finger sucking) and may in fact not reflect psychological abnormalities. In the Isle of Wight study (Rutter et aL, 1970, p. 213) these same items also failed to differentiate between the psychiatric group and the general population. This shed further doubt on Cederblad's (1968) conclusions suggesting that symptom load be based on just these types of behaviours. However, the Ugandan control and school problem children also did not differ on items describing wetting and general speech difficulties. This was mainly due to the lower rate of recorded abnormaUties in the Ugandan sample and may reflect a cultural difference. Looking at the children in the reform school 15 items did not differentiate the neglected from the delinquent group. Four of these items (12, 13, 21, 23) correspond to those which also failed to differentiate between the two school groups. Although
CHILDREN IN UGANDA
33
one might expect more differences between the two reform school groups as the children had come to the school for very different reasons, teachers tended to give very high scores to all reform school children. As no comparative British data on delinquents are available it is difficult to say whether these higher scores in the reform school children are due to the slightly older age of the reform school sample or reflect a negative "halo effect" biasing the teacher's perception, or whether they represent a genuinely high rate of psychological deviance. Clinically, the delinquent children certainly showed many traits indicative of severe psychosocial disturbance. A number of them had stolen valuables and clothing from their own famihes while they worked on the fields and at times sold them as far away as Kenya following long stowaway railroad trips. Others needed regularly to smell or drink petrol or smoke marijuana and would seU their own blankets and food in neighbouring villages to obtain the necessary money. One 12-yr-old boy had gone as far as making a master key out of chicken bones which allowed him to steal the school's total cash. These and similar histories explain why the delinquent children were most frequently seen as children who had acting out disorders of one kind or another (65%). While this favours the explanation of a genuinely high rate of psychological deviance it must be remembered that all diagnoses were arrived at by the author who was not blind as to the labeUing ofthe child by his teachers and parents or housemasters. The author certainly attempted to decide upon a diagnosis without being unduly influenced by either symptom check list. While he initially knew the number of positive symptoms rated by the teachers he had not calculated the factor score at the time ofthe chnical evaluation. He also assessed and diagnosed the children prior to giving the symptom check list to their parents or housemasters. Analysis of the distribution of the diagnostic categories between the various samples gave some specific results. Girls in the schools and clinic sample did not receive significantly different diagnoses. As the number, especially in the clinic group, was very low, this may be a spurious finding. When both groups of girls were combined and compared with either group of boys, the girls tended to show fewer acting out disorders than the boys, although this difference was not quite statistically significant. This finding again, corroborates studies in developed countries {Rutter etal., 1970). The problem schoolboys, however, differed significantly from the male clinic sample as they showed a higher incidence of behaviour disorders and had fewer children in the "other" category which denoted primarily the presence of a psychosomatic disorder. This implies that a good number of children attending a child psychiatric clinic in Africa arc brought because of functional complaints, such as abdominal pain, rather than primary behaviour symptoms. Such pain is generally perceived as reflecting an organic illness that requires medication from a doctor. Interpretations which stress the possible conflictual interpersonal origin of a functional symptom are not easily accepted l)y parents and teachers, although the power envious neighbours or relatives may have upon psychological function is readily seen by everyone. Thus, the psychiatrist who works only in a hospital setting is confronted with a cultural system which gives him privileged access to children with psychosomatic di.sorders but does not easily permit him to influence attitudes pertaining to the emotional needs of children in general. The data in this study
34
KLAUS K. MINDE
clearly indicate that Ugandan children show symptoms comparable to those exhibited in developed countries although in Africa the symptoms are seen as mere forms of nuisance which require punishment by an adult. This was confirmed in the clinical interviews during which the teachers and parents were asked what other symptoms, not included in the symptom check list, their child showed. In response, both groups most commonly referred to a particular child's disrespect for his elders whom he was said to "abuse" verbally and to his unwillingness to perform the many duties even young children have in their homes. The latter problem was generally labelled "laziness" and was applied to children who occasionally refused to sweep the house and yard, help in the fields, collect firewood or prepare meals. The clinical diagnoses given to the problem school children appeared to reflect these sentiments by stressing the predominantly reactive nature of their problems (reactive behaviour disorders) or the children's deviant response to adolescence or other developmental milestones (healthy responses). It now seem important to follow up these leads and construct symptom check lists which incorporate items primarily meaningful in the African context. The extent to which these symptoms show themselves in various life situations is examined in the evaluation of factor scores obtained from the symptom check lists of parents and teachers. This in itself is a procedure not used by those who designed these scales initially and is fraught with obvious dangers. Nevertheless, as the author at the time of the actual data collection was ignorant of the parental scale which complements the teacher rating scale and makes an item comparison possible, he saw no other way of comparing the two different assessment measures. To what extent the fairly high concordance of factor scores obtained among parents and teachers truly reflects commonalities in the children's behaviour is difficult to determine. Some ofthe individual cells have very low frequencies. This reduces the weight one can give to the statistical findings and allows only very tentative interpretations. It appears, however, that the main discrepancy between the two scales stems from boys who are labelled neurotic by their parents and seen by their teachers as conduct disorders. The girls, on the other hand, are seen more often as neurotic by their teachers than their parents. An explanation of this finding is difficult but may be sought in the specific cultural situation. Girls in the Ugandan home are expected to be even more docile than boys. Hence any "abnormal behaviour" may only be able to go in the direction of self-assertiveness, viewed by the parents as "acting out". In contrast disturbances in the culturally more active boys may be perceived as increased withdrawal and shyness. As school authorities do not share these stereotyped sex role expectations, disturbances in this milieu may indeed take other forms. Turning to the reform school one finds the dehnquent boys showing a pattern similar to that ofthe school boys. Unfortunately, the housemasters of only 17 ofthe children completed the symptom check list as some of them were not familiar enough with the individual children (there were 25-30 children per housemaster) or had only recently been transferred to the particular group of youngsters. This may have lowered the statistical confidence of our findings in ihis group. As 10 out ofthe 20 neglected reform school youngsters had a normal teacher's symptom count and the housemasters rated 70% of them also within normal limits
CHILDREN IN UGANDA
35
the remaining number of abnormal children was too small to be included in the factor comparison. Although teachers and parents agree significantly on the main focus of the child's disturbances, the clinical diagnosis shows less concordance with the symptom check list factors. This is especially true for the school children diagnosed as reactive behaviour disorders. Ofthe 26 school children so diagnosed, 10 had high parental neurotic scores, four high parental and teacher conduct scores and 12 had less pronounced symptom patterns. Likewise, four of seven conduct disorders had high conduct scores in both the teacher and parental scales. It is also interesting to note that the great majority of other diagnoses made by the author corresponded with the preponderance of neurotic symptoms on the parental check list. This may indicate that behaviour classified as "neurotic" in these symptom check lists in Africa represent a conglomerate of psychological maladjustments which are primarily characterized by an absence of acting out or anti-social behaviours. The child, nevertheless, may show these symptoms in response to stressful external events, developmental huidlcs or as an expression of functional physical complaints. The findings for both the delinquent and clinic groups are similar. In all but one child the housemasters rated the reform school children diagnosed as personality disorders high on the conduct factor and those seen as reactive behaviour disorders as either neurotic or low on both the conduct and neurotic factor. The clinic population showed similar trends. Ofthe eight children diagnosed as behaviour disorders four had a high neurotic score (above 10) while only one had a high conduct score. Other children with high neurotic scores were diagnosed as psychoneurotic (2 children) and psychosomatic disorders (3 children). Children from both the school and clinic populations who were diagnosed as essentially normal or merely physically ill, generally had a lower parental check list score than those given a positive psychiatric diagnosis (total score 9-8 vs 16-3). These results may be a reflection of the author's bias in unwittingly basing his diagnosis primarily on the account of the parents rather than the teachers. In the original data (Rutter et al., 1970, p. 174), about 40% of all parents whose children were given positive psychiatric diagnoses saw their children as having no more problems than most other children. In these data the parental check list scores also agreed most strongly with an overall measures of psychiatric disorder. The percentage of Ugandan parents who at the outset ofthe interview denied any problem in their children or saw none more serious than in most other children was somewhat lower (15 parents = 32%) than in Rutter's original data although five parents in the subsequent symptom enquiry reported a high number of abnormal behaviours. There were also four parents among the 48 controls who rated their children as disturbed. Two of these children were in fact diagnosed as behaviour disorders by the author while the other two were seen as normal. There were a further two control children who were diagnosed as adjustment reaction (healthy responses) who had not received a high score from their parents, making for a total false negative rate of about 8% among the controls. This would speak against an undue influence of the parental opinion upon the examiner's diagnostic choice but supports the possibility that Ugandan parents do know more about their children than teachers and are in fact willing to talk about these problems to an interested person. This possibility
36
KLAUS K. MINDE
is supported by data presented in another paper (Minde, 1976) which documented that treatment suggestions made by the author or his assistants were wilUngly accepted and carried out weU by the families and teachers. In summary, it can be said that behavioural screening techniques developed in western countries yield a substantial number of school aged children in East Africa who upon close examination show psychiatric symptomatology both at home, at school and on clinical psychiatric examination. While some specific symptoms such as masturbation or bed-wetting are very rarely encountered in Uganda, the majority ofthe screening test items seem to possess transcultural relevance. This supports the increasing evidence (Rutter et aL, 1974) that familial risk factors associated with psychiatric disorders are valid in many cultures and that the behavioural expectations of school age children in Uganda and Britain are quite similar in terms of clinical practice. It also strongly suggested that child psychiatrists in order to have a true impact on the developmental needs of children in developing countries may need to combine hospital based chnic work with active community involvement as children with primary behaviour symptoms in Africa typically are not sent to hospitals but must be found and treated in the comn:iunity. SUMMARY A total survey of psychiatric symptoms of primary school children attending three schools in economically distinct areas of Uganda was made. The symptoms were compared with those displayed by primary school aged children committed to a reform school and patients attending a child psychiatric outpatient clinic in the same country. Results indicate that high and low scoring school children and reform school children have different family backgrounds. There was good correlation between parent and teachers in identifying disturbed youngsters and characteristic diagnostic patterns of school and clinic children. The significance of these findings is discussed in terms of the role child psychiatry may play in developing countries. Acknowledgements—This study was supported by East African Community Grant number 523513-006. I would also like to thank Mr. S. Kiwanuka, and all the headmasters and staff of Naguru, Kinseye and Lutete Primary Schools and Kampiringisa Reform School for their assistance and continuous support. REFERENCES ASUNI, T . (1970) Problems of child guidance ofthe Nigerian school child. W. Afric. J. Educ. 14,49-52. CEDERBLAD, M . (1968) A child psychiatric study on Sudanese Arab children. Acta Psychiat. Scand. Suppl. 200. GAP (1966) Psychopathol(^ical disorders in childhood: theoretical considerations and a proposed classification. Croup for the Advancement of Psychiatry, Vol. VI, Report No. 62. GERMAN, G . A. (1972) Aspects of clinical psychiatry in sub-Saharan Africa. Br. J. Psychiat. 121, 461479. GIEL, R . and VANLUIJK, J. N. (1969) Psychiatric morbidity in a small Ethiopian town. Br. J. Psychiat. 115, 149-162. GiEL, R., BiSHAW, M. and VANLUIJK, J. N. (1969) Behaviour disorders in Ethiopian children. Psychiat. Neurol. Neurochir. 72, 395-400. GOODALL, J. (1972) Emotionally induced illness in East African children. E. Afric. Med. J . 49,407-412.
CHILDREN IN UGANDA
37
HOLLINGSHEAD, A. and REDLICH, R . F . (1958) Social Class and Mental Illness. A Community Study. Wiley, New York. IZUORA, G . E . A. (1970) Mental health of children in developing countries. Proceedings 2nd PanAfrican Psychiatric Workshop, p. 59. Mauritius. LEIOHTON, A . H . , LAMBO, T . A., HUGHES, C . C , LEIGHTON, D . C , MURPHY, J. M. and MACKLIN,
D. B. (1963) Psychiatric Disorder Among tlie Toruba. Cornell University Press, Ithaca. N.Y. MBANEFO, S. E . (1971) The general practitioner and psychiatry. In Psychiatry and Mental Health Care in Ceneral Practice. University of Ibadan, Department of Psychiatry and Neurology. MINDE, K . (1974) The first 100 cases of a child psychiatric clinic in Uganda: a follow-up investigation. East Afric. J. Med. Res. 1, 95-108. MINDE, K . (1975) Psychological problems in Ugandan school children: a controlled evaluation. J. Child Psychol. Psychiat. 16, 49-59. MINDE, K . (1976) Child psychiatry in developing countries: some lessons learned. East Afric. J. Med. Res. (in press). NURCOMBE, B. and CAWTE, J. E. (1967) Patterns of behaviour disorder amongst the children of an aboriginal population. Anst. NZ- J- Psychiat. 1, 119-133. PiiTERsoN, P. R. and QUAY, H . C . (1967) Factor analyzed problem checklist. University of Illinois, Children's Research Center, Urbana, IL. RAHIM, T. H . (1972) Psychiatric disorders in the Red Sea children. Paper presented at the Zrd PanAfrican Psychiatric Congress, Khartoum, November. RUTTER, M . (1967) A children's behaviour questionnaire for completion by teachers: preliminary findings. J . Child Psychol. Psychiat. 8, 1-11. RUTTER, M.,TIZARD, J. and WHITMORE.K. (1970) ^tfuci/r/onj/Zea/Z/tanrfBeAflWow^ Longmans, London. RUTTER, M . (1971) Parent-child separation: psychological effects on the children. J. Child Psychol. Psychiat. 12, 233-260. RUTTER, M . , YULE, W . , BERGER, M . , YULE, B., MORTON, J. and BAGLEY, C . (1974) Children of
West Indian Immigrants—I. Rates of behavioural deviance and of psychiatric disorder. J. Child Psychol. Psvchiat. 15, 241-262.
CHILDREN IN UGANDA: RATES OE BEHAVIOURAL DEVIATIONS AND PSYCHIATRIC DISORDERS IN VARIOUS SCHOOL AND CLINIC POPULATIONS KLAUS K . MINDE*
Department of Psychiatry, The Hospital for Sick Children, University of Toronto INTRODUCTION COMPARATIVE estimates of the prevalence and types of psychiatric disorders in different cultures are of importance in delineating the degree to which such disorders are culture bound in their general manifestations. Yet there are many difficulties in pro\'iding reliable data on mental disorders for African countries because these countries are frequently neither an ethnic nor a cultural entity but consist of a multitude of distinct cultures. One further major problem is that psychiatric research reports from Africa have almost exclusively been offered by European psychiatrists who have an unavoidable ethnocentric bias. African researchers have nearly all been trained in Europe and the U.S.A. and have not yet developed an indigenous African school of psychiatry. Moreover, research techniques developed in the industrialized nations do not always fit the African situation since populations are often illiterate, family names non-existent and demographic statistics are unavailable. Despite these severe limitations recent work has been carried out and indicates that the incidence of psychiatric illness in new adult outpatients coming to a small general hospital in Uganda (German, 1972) or Ethiopia (Giel and Van Luijk, 1969) and a semi-rural clinic in Nigeria (Mbanefo, 1971) is about 15-20%. Leighton et al. (1966) visited 15 villages and a small city in Western Nigeria and counted the psychiatric symptoms of 326 men and women. Of all adults examined 40-45% were found to show psychiatric impairment (pp. 124-137). Work with children has been much more impressionistic. Izuora (1970) and Asuni (1970) described a mental health clinic in Enugu and Eagos respectively but gave only a very general description of their patients, citing their age, sex, and diagnosis. Goodall (1972) described seven particular cases attending a general paediatric outpatient clinic in Kampala but gave no indication of the rate of emotional disorders among her clinic population. Rahim (1972) reviewed the clinical diagnoses of 319 children seen in Port Sudan over a 6 yr period but did not specify the criteria used in arriving at his diagnostic categories. Okasha et al. (1972) described the symptomatology of 134 depressed children seen in Cairo over a 3 yr period. The authors differentiated between children with phobic depression, enuretic
•Address for reprints: Department of Psychiatry, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Ontario, Canada. 23
24
KLAUS K. MINDE
and manic depression and those labelled "depressives". The symptoms leading to their respective diagnoses such as "difficulties at school", "immaturity", "lack of confidence", "warm personality", were not operationally defined and hence cannot be replicated. Giel et al. (1969) went beyond the case description of patient samples and studied the psychiatric morbidity of two Ethiopian villages. They found that 3-4% of all children under the age of 9 and 10% of those 10 yr and older showed psychological abnormalities. No detailed breakdown of symptomatology was given. The author, in previous publications (Minde, 1974, 1975), has examined the incidence and treatment of psychiatric difficulties in various child populations in Uganda more systematically, and found the global incidence of psychiatric disturbance in primary school children to be 18% with a high rate of 24% in an urban setting and 10-5% in a rural area. A single study, by Cederblad (1968), focused on specific psychological symptoms in children. She screened all 1716 children aged 3-15 who lived in a Sudanese village of about 5000 with respect to stuttering, sleep walking, enuresis, encopresis and sleep disturbances. Children showing more than one of the above symptoms and a Swedish control group were then studied in more detail [N = 197). Gederblad found the Sudanese children to have a generally lower rate of severe symptoms than those ofthe Swedish sample (8 vs 25%). The Sudanese, however, showed a higher incidence of aggression and nocturnal enuresis than their Swedish controls. There are, however, a number of problems with the study. The questionnaire used in Cederblad's study has not been documented to contain items primarily denoting psychopathology. In fact, many ofthe items differentiating the European and African sample (e.g. enuresis, sleep disturbance), are of questionable psychiatric significance. The interviews were performed by medical students unfamiliar with psychiatric phenomenology and interview techniques. They were also often held in the presence of neighbours and other onlookers. These factors may have reduced the reliability of results. No attempts were made to validate the mothers' behavioural observations by others familiar with the children, such as teachers or other relatives. In summary, the African literature provides increasing evidence that a number of African children suffer from psychological disorders and are given diagnostic labels originally created to describe European children. It is not known whether these labels give an adequate picture ofthe disturbance as it is perceived by Africans themselves and whether the symptoms which contribute to making a particular psychiatric diagnosis are comparable in Africa and Europe. Furthermore, it is not known whether English questionnaires with their abstract description of individual behaviours can be translated into a Bantu language which in its structure favours detailed descriptions of events over words noting abstract concepts. Finally it is not known whether any psychiatric disorders of African children described by their parents are also reported by their teachers. The present investigation attempts to fill these gaps. METHOD Setting
Uganda, situated in East Africa, straddles the Equator and is about the size of Great Britain. The country has been independent since 1962 and is populated by various tribal groups who speak differ-
CHILDREN IN UGANDA
25
ent languages and have attained various levels of education and economic sophistication. While the northern parts have distinct dry and rainy seasons, the south gets evenly spaced rain, making it one ofthe most fertile regions in the whole of Africa. Coffee, tea and cotton provide the bulk ofthe cash income for the country's ten million inhabitants. The present study includes only children living in Buganda, the most developed province in the south of the country where people speak one common language and primary school attendance has reached about 50%. This allowed us to work in one language and within one cultural eontext. Subjects (a) Primary schools. All children attending grades 2-7 aged 7-15 in three primary schools participated in the study (N — 577). School I was situated in a remote rural area with no medical and very poor academic facilities. The school building was made out of mud and one class was instructed under a tree as its room had collapsed. There were only 20 pencils for the lower four grades and one book per classroom. Teachers were poorly trained. All people in the area lived on subsistence farming. School II was 35 miles north ofthe capital in a fertile rural district, had semi-permanent structures, well trained teachers and an excellent Maternal and Child Health Centre nearby. The population in the area farmed but some had established contacts with hotels or other institutions in the capital and sold their produce regularly. School III was in the capital and frequented by lower middle-class African children. The school had the best equipment of all three institutions and at times even teachers trained in specialties such as science and music. The children's parents worked in lower government positions or were tradesmen. (b) Reform school. M\ primary school age youngsters (15 yr and under) committed by various courts to the only reform school in Uganda participated in this study {N = 68). Ihis group WM divided into those cliildren committed for delinquent offences (delinquent chiidren, N = 48) and those admitted as "care and protection" cases (neglected children, N — 20). The school had only boys. (c) Outpatient clinic. All children aged 6-15 attending a child psychiatric outpatient clinic for the first time within a 6 month period were included in the study (N ~ 61). Procedure
The research strategy was based on a two-stage procedure. Initially the teachers of all children in the primary and reform schools were asked to complete a symptom screening test developed by Rutter (1967) Children whose scores suggested the presence of a psychiatric disorder were matched on sex and age with controls and then interviewed more intensively. Their parents were also visited and given a semi-structured interview, using the Peterson-Quay Symptom Check List (1967) as a symptom inventory. The latter Symptom Check List was used because the author at the time ofthe research planning did not know of the existence of the parental symptom screening instrument developed by Rutter et al. (1970). Both scales were used because they had been factor analyzed for children of similar ages, had been used in a number of investigations assessing British (Rutter et aL, 1970) and West Indian children (Rutter et al.., 1974) and were familiar to the author. After both family and child had been interviewed clinically by tbe author, but before tbe individual factor scores of the teacher and parental scales were computed, the author assigned a clinical diagnosis to each child, using the GAP classification (1966). This classification is widely used in North America, has been shown to be applicable to other cultures (Nurcombe and Cawte, 1967) and was familiar to the author. .Ml outpatients attending the child psychiatric clinic for the first time were screened elinically and divided into those presenting with severe organic handicaps and those with bebavioural abnormalities. Only the latter group was investigated in more detail. (a) Screening procedures. Rutter's teacher's questionnaire, which asked teachers to rate each child in his/her class on 26 specific behaviours, was used as the primary screening instrument in the public and reform schools. The questionnaire requires ihe teacher to note whether any of the stated behaviours "does not apply", "applies somewhat" or "very much". This questionnaire was translated into Luganda, the indigenous language of the province all children and their teachers came from. The translation was done by one graduate social worker who had done part of his training in the
26
KLAUS K. MINDE
U.K. and one psychologist who had obtained her M.A. in the U.S.A. As Luganda often does not have single word equivalents for the more abstract concepts asked for in the questionnaire (e.g. question 3, "squirmy child", in Luganda reads—"moving tbe limbs pretty fast in a funny way like the Konga monkey"), the questions were retranslated into English by another person. This provided a check on tbe clinical specificity ofthe questions. In addition, the questionnaire was presented to three primary school teachers, one of whom had trained in Ireland, to assess the relevance ofthe itenns for a school situation. All the items were felt to be potentially observable in a school situation but they were generally not considered to be part of a normal Ugandan school child's behavioural repertoire. The outpatient clinic screening was done by an assistant who also functioned as an interpreter. The assistant enquired about the age of the child and parents, parental occupation, and the type of house tbey lived in. He also noted age of siblings, the type of family the child lived in, the number of moves he bad in his life, his developmental milestones, as well as previous medical and school history. All those children presenting with severe developmental delays and/or a history indicatii^ cerebral insults, including epileptic seizures, were excluded from further study. (b) Individual examinations. Each child with an abnormal score (9 or more) on the teacher's questionnaire were selected for a possible furtber study. This included a previously described interview with the child (Minde, 1975) and a 1-2 hr home visit during whicb specific background and developmental data were obtained. In addition, each parent was given the Peterson-Quay Symptom Check List (1967). This check list requires the adult to indicate wtiether 55 specific behaviours "never occur", "sometimes occur", or "often occur". Tbe questionnaire was translated into Luganda and each question read to the parents by an assistant in the presence of the author. Following the interview the author assigned a clinical diagnosis to each child, using tbe GAP classification (1966). Out of the total of 577 primary school children 105 scored within the abnormal range on the teachers' questionnaire. As time did not permit studying them all, the two to three children with the highest score in each primary class were selected for furtber study and matched with a classmate of the same sex and age whose score was amongst the lowest. A total of 48 problem and 48 control children, representing extreme scores on either end, were evaluated. The reform school had 68 children in tbeir junior section who attended scbool witbhi the institution. Of these, 48 had been committed because of deliquent acts and 20 because of severe parental neglect. Forty-six of the 48 delinquent children scored 9 and bigher on the teacher's questionnaire whereas only 10 out of the 20 neglected cbildren did so. Only 3! of tbe total group were bom in Buganda, the others came from nine other tribes. Yet all children had been at tbe institution for at least six months and were conversing in the local language. Two teachers did not speak Luganda as their mother tongue and rated the children on tbe English version ofthe teacher questionnaire. Half of the higb scoring delinquent children and each neglected child was studied in detail (23 vs 20 cbildren). Tbe housemaster of each reform school child filled in the Peterson-Quay Symptom Check List in place ofthe parent. A total of 61 children aged 6-15 presented to the outpatient clinic. Of these 27 had primary behaviour disorders and were evaluated further. Only 13 of these 27 children attended school. As these children all came from different schools many miles apart the teacher's questionnaire could not be used in this population. The home visit was also replaced by an interview at the clinic where tbe parent was given the Peterson-Quay Symptom Check List by the author.
RESULTS
Table 1 indicates that age differs significantly only between the reform school boys and those in the clinic and school populations. The reform school boys were significantly older {t = 4-56, d.f. -= 94,/» < 0-01). The social class of the children was assessed using a modification of the five classes delineated by Hollingshead (1958). The classes were as follows: Class 1: Professionals with university education; Class 2: senior government officials and owners of large businesses who had secondary school education up to
CHILDREN IN UGANDA TABLE 1. AGE
mean s.d. N
School Problem Control Boys Girls Boys Girls 11 -2 12-2 10-9 12-1 2-4 18 2-5 2-0 30 18 30 18
27
(yr) Clinic Boys 10-4 3-1 18
Girls 10-6 3-0 9
Reform school Delinquent Neglected Boys Boys 13-1 12-9 1-3 17 23 20
S4; Class 3; junior civil servants, primary school teachers, policemen, clerks; Class 4: craftsmen, farmers owning more than three acres, mechanics; Class 5: small plot farmers, unskilled labourers. Table 2 indicates that social class was similar for the various groups. TABLE 2. SOCIO-ECONOMIC CLASS
I + II
III
IV f V
2 5 5
11 8 6 5 2
34 32 16 16 17
C-I
School problem School control Clinic Reform delinquent Reform neglected
1
X' = 6-97
d.f.^
8 n.s.
Further background data are reported in Table 3. Boys and girls in botli the school and clinic population did not vary in any of the background criteria. Consequently, in subsequent analyses sexes were combined. All groups scoring in the abnormal range on the Rutter scale had significantly more broken homes (x^ = 5-5, ^•/ = ^,P < 0-02, for controls vs problem boys; x^ = B-15, d.f. ^ \,p < 0-01 for' control vs clinic children) than the school controls with the reform school children having an even higher rate of broken homes than the two other patient populations. (X^ = 6-34, d.f. = l,p < 0-02, clinic children vs delinquents.) The presence of past serious medical illnesses and parental death did not differentiate the groups. TABLE 3. BACKGROUND DATA
Broken home 1 parent dead Bad moves Serious medical illness
School Problem Control 39-5 14-5 8-3 104 41-6 12-5 18-7 229 - 48
jV = 48
Clinic (°/ ) 444 18-5 22-2 22-2
Reform del. (%) 73-9 19-5 41-3 19-5
Relbrm neg. (%) 75-0 25-0 50-0 35-0
.V = 27
A" == 46
N ^ 20
\
/a)
Tables 4 and 5 compare the various patient and the school control groups on the two symptom check lists used in the investigation. Table 4 gives the sum totals ofthe various groups. The student /-test revealed no statistical significance between boys and girls in the school and clinic samples. The dehnquents scored significantly higher than their neglected schoolmates on the teacher rating scale {t = 5-53,
28
KLAUS K. MINDE
d.f.^A\,p < 0-001), but not on the ratings of their housemasters ( / = 1-29, (/./. = 41, n.i.).'The primary school problem children scored significantly higher than their controls on both the teacher symptom ratings {t = 12-9, d.f = 94, /? < 0-001) and the parent symptom ratings [t = 4-28, d.f = 94, p < 0 - 0 5 ) . TABLE 4. TOTAL SYMPTOM CHECK LIST SCORES
Boys N = SQ Girls j V = 18
mean s.d. mean s.d.
Primary schools Controls
Boys A - = 30 Girls N = 18
mean s.d. mean s.d.
Clinic group
Boys J V = 18 Girls N =9
mean s.d. mean s.d.
Delinquent .M=23 Neglected JV-20
mean s.d. mean s.d.
Primary schools Problems
Reform school
Teachers 15-8 58 14-8 6-7 1-4 19 1-6 17
Parents 17-6 11-1 161
HI 6-4 46 3-2 1-5 13-1 12-6 110 9-3
20-1 7-1 9-8 6-2
33-4 16-8 21-0 23-5
Table 5 compares the primary and reform school population on each item of the teacher's questionnaire. A preliminary analysis comparing both the problem boys and girls of each primary school with those of the other two primary schools revealed only one differentiating item. The city school had significantly more children which were seen as hyperactive by their teachers (Teacher's Questionnaire item No. 1) than both country schools, (x^ = 10-6, d.f. = l,p < 0-05.) The relative homogeneity among the three primary schools permitted a combined analysis. The four groups were compared with each other on each item of the teacher's symptom check list, using the three possible answers to each question (doesn't apply, applies somewhat, applies very much) in a 2 X 3 /^ analysis. To facihtate the reading of the table, however, Table 5 records only the total percentage of children who scored "applies somewhat", and "apphes very much", on each item. Looking first at problem school boys and their controls the table shows that items 12, 13, 21, 23 and 25 do not differentiate between these groups. Only item 14 does not differentiate between controls and reform school delinquents but items 1, 2, 12 13 21, 22, 23, 24 and 25 do not between the controls and the neglected boys at the reform school. The delinquents scored significantly higher than the problem school boys on items 1, 12, 13, 17, 20, 21 and 23 with the school boys scores being higher on item 14. The neglected reform school children scored significantly higher than the problem school youngsters on items 17 and 20 and significantly lower on items 2 and 14.
29
CHILDREN IN UGANDA TABLE 5. COMPARISON OF ITEMS ON TEACHER SYMPTOM CHECK LIST (%)
No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
Individual item Very restless Truants from school Squirmy fidgety child Often destroys own or others belongings Frequently fights with other children Not much liked by other children Often worried Tends to do things on his own Irritable Miserable, unhappy, tearful or distressed Twitches, mannerisms/ticks Sucks thumb/fingers Bites nails/fingers Absent from school Is often disobedient Poor concentration, short attention span Fearful/afraid of new things Fussy/over-particular child Tells lies Has stolen things Has wet/soiled self Complains of aches or pains Tears on arrival at school S tut ters/s tammers Other speech difficulty Bullies other children Total A"
School Reform school Problem Control Delinquent Neglected 43-3 13-3 65-2 35-0 43-3 0-0 41-3 5-0 53-3 3-3 73-9 45-0 40-0 3-3 58-7 35-0 43-3 6-6 60-9 30-0 56-6 0-0 80-4 30-0 53-3 10-0 65-2 70-0 200 53-3 73-9 55-0 633 0-0 76-1 70-0 66-6 10-0 69-6 40-0 23-3 3-3 45-7 40-0 6-6 3-3 34-8 15-0 10-0 66 41-3 20-0 63-3 13-3 34-8 20-0 500 0-0 76-1 30-0 70-0 6-6 71-7 50-0 433 3-3 65-0 78-2 36-6 3-3 60-9 25-0 633 0-0 78-2 45-0 266 0-0 63-0 60-0 33 00 47-8 25-0 50-0 6-6 54-3 25-0 10-0 6-6 41-3 0-0 16-6 3-3 32-6 10-0 3-3 6-6 28-2 25-0 40-0 100 58-7 20-0 30
30
43
20
Following the comparison for each item the factor scores indicating the presence of a neurotic or conduct disorder were determined for each child. These factors had been derived by Rutter et al. (1970) through factor analysis ofthe total scale and took in four items for the neurotic and six items for the conduct disorder. These factor scores were then compared with the neurotic and conduct factor score of the parental symptom check hst. The parental factors had also been arrived at by the originators of this scale (Peterson and Quay, 1967) and out ofthe total of 55 items took in 14 items for the neurotic and 17 for the conduct rating. This factor score comparison between teacher and parent ratings was thought to be more appropriate than an individual item comparison ofthe two scales for a number of reasons. The parental scale had about twice as many items as the teacher's scale, making it rather long for item-by-item presentation. Also, while Rutter et al. have pubUshed their raw data, thus allowing comparison of their data with those of African children in the present study, no such data are available for the North American children used in the Peterson-Quay scale. Table 6 indicates that teachers and natural parents significantly agree on labelling their boys and girls as having a neurotic or conduct disorder. Agreement did
CHILDREN IN UGANDA
31
diagnoses (sociosyntonic behaviour disorder) than all other groups {x^ = 3-49, d.f.= 1, /* < 0-1 vs neglected children and x^ = 5-88, d.f. = \,p < 0-02 vs school boys) and were less often seen as behaviour disorders than the school boys (/^ = 4-56, d.f ^- \,p < 0-05).
To assess the agreement between the psychiatric diagnosis and the parents' and teacher's evaluation, a final analysis was performed which compared the diagnosis given to each problem child with his factor scores on the parental and teacher questionnaire. The results showed that teacher ratings alone did not correspond to the fmal diagnosis made by the author as highly as the parental factor scores. The following pattern emerged. Tiie 18 school children who scored higher on the neurotic than on the conduct factor were diagnosed as either "reactive behaviour disorders" (10 children) or as "developmental deviation; situational stress; neurotic behaviour; or psychosomatic disorder" (8 children). The latter group comprised 80% of children so diagnosed. In all children scoring 10 or higher on the parental conduct factor the clinical diagnosis was "personality disorder" (4 children) or "reactive behaviour disorder" (4 children). In these eight cases the teacher questionnaire also indicated the prevalence of conduct over neurotic items. Among the five delinquent reform school children chnically diagnosed as behaviour disorders three scored higher on the neurotic than on the conduct factor on the parental scale while the other two showed conduct factor ratings under 10. The teachers rated one as neurotic, one as equal and three as conduct disorders. The other 12 children who were diagnosed as personality disorders (tension discharge or sociosyntonic disorder) with only one exception scored above 10 on the parental conduct factor and in 10 instances were rated as conduct disorders by their teachers. DISCUSSION The present study will be discussed both from a methodological and clinical point of view The 166 children examined appeared to be a substantial number. Yet subsample size is small, especially for girls, and makes any generalization ofthe data to other parts of Uganda or Africa hazardous. The results nevertheless bring out a number of interesting facts. Girls are under-represented in both the school and clinic samples. This was not primarily due to selective school attendance, as the enrolment of girls in these schools was close to 45%, but to the smaller number of girls who were seen as behaviourally deviant by their teachers and/or parents. In addition the schoolgirls were somewhat older than the schoolboys. This suggested that disturbing symptoms in girls manifest themselves later than in boys or that they are milder and take longer to identify. The question to what degree school children in a developing country are representative of tlie child population in general is difficult to answer. The author with the help of the local chiefs and others familiar with the local area, unsuccessfully tried to find families in any of the school districts who had never sent a child to school. Each family which was thought to qualify had at least one of their children in school, often on a rotating basis, and would have sent more if their financial situation had allowed it. This would indicate that school children, at least in the
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KLAUS K. MINDE
districts under study may present a fairly adequate reflection of all children in the population. The socio-economic homogeneity of the total sample is not surprising. The great majority of Africans still live on subsistent farming or have relatively unskilled occupations. Future changes may be reflected in the clinic population where almost 40% of all children came from upper or middle-class homes. Further background data confirmed previous impressions by the author (Minde, 1975). They indicate that children who come from homes which have broken up because of divorce or desertion of one parent are significantly more Ukely to be disturbed and that this is especially evident in children who end up in a reform school. The reform school children, especially those admitted for "care and protection" had in addition lost the support of their extended families. Their life styles were frequently endless repetitions of tragic events rarely encountered even in the most deprived parts of our cities. There were children wandering through the country from age 7 onwards, living off the land, being exploited and mishandled until they were finally picked up by the police and often placed with adult criminals in prison cells. Others stole a bit of food or a shirt as they had not been given any food for days, were caught, beaten and then sentenced to up to three years in a reform school. The disintegration of the families is confirmed by the high percentage of all problem children who had experienced a move which was not in keeping with tribal traditions. This has been discussed in a previous paper {Minde, 1975) and implies that these children had to leave their homes because their families broke up or they were dismissed rather than because an aunt who lived closer to school wanted the child to stay with her. Parental death was most common among the "neglected" group but did not differentiate the problem from the control school children. This lends support to a recent study by Rutter (1971) which shows that the death of a parent is less traumatic for British children than parental quarrels. The use of a rating scale devised for European children in an African setting was naturally approached with a good deal of initial hesitation by the author. However, after assessing a good number of children in the outpatient cHnic and on paediatric wards and after discussion with a number of African medical colleagues, he did feel that at least some behaviours were considered abnormal in both cultures. The item analysis ofthe teacher symptom check list lends support to this impression in that only 20% of all items did not diflferentiate between control, problem school, and neglected reform school children. These items were mainly indicating habit disorders (e.g. nail biting, finger sucking) and may in fact not reflect psychological abnormalities. In the Isle of Wight study (Rutter et aL, 1970, p. 213) these same items also failed to differentiate between the psychiatric group and the general population. This shed further doubt on Cederblad's (1968) conclusions suggesting that symptom load be based on just these types of behaviours. However, the Ugandan control and school problem children also did not differ on items describing wetting and general speech difficulties. This was mainly due to the lower rate of recorded abnormaUties in the Ugandan sample and may reflect a cultural difference. Looking at the children in the reform school 15 items did not differentiate the neglected from the delinquent group. Four of these items (12, 13, 21, 23) correspond to those which also failed to differentiate between the two school groups. Although
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one might expect more differences between the two reform school groups as the children had come to the school for very different reasons, teachers tended to give very high scores to all reform school children. As no comparative British data on delinquents are available it is difficult to say whether these higher scores in the reform school children are due to the slightly older age of the reform school sample or reflect a negative "halo effect" biasing the teacher's perception, or whether they represent a genuinely high rate of psychological deviance. Clinically, the delinquent children certainly showed many traits indicative of severe psychosocial disturbance. A number of them had stolen valuables and clothing from their own famihes while they worked on the fields and at times sold them as far away as Kenya following long stowaway railroad trips. Others needed regularly to smell or drink petrol or smoke marijuana and would seU their own blankets and food in neighbouring villages to obtain the necessary money. One 12-yr-old boy had gone as far as making a master key out of chicken bones which allowed him to steal the school's total cash. These and similar histories explain why the delinquent children were most frequently seen as children who had acting out disorders of one kind or another (65%). While this favours the explanation of a genuinely high rate of psychological deviance it must be remembered that all diagnoses were arrived at by the author who was not blind as to the labeUing ofthe child by his teachers and parents or housemasters. The author certainly attempted to decide upon a diagnosis without being unduly influenced by either symptom check list. While he initially knew the number of positive symptoms rated by the teachers he had not calculated the factor score at the time ofthe chnical evaluation. He also assessed and diagnosed the children prior to giving the symptom check list to their parents or housemasters. Analysis of the distribution of the diagnostic categories between the various samples gave some specific results. Girls in the schools and clinic sample did not receive significantly different diagnoses. As the number, especially in the clinic group, was very low, this may be a spurious finding. When both groups of girls were combined and compared with either group of boys, the girls tended to show fewer acting out disorders than the boys, although this difference was not quite statistically significant. This finding again, corroborates studies in developed countries {Rutter etal., 1970). The problem schoolboys, however, differed significantly from the male clinic sample as they showed a higher incidence of behaviour disorders and had fewer children in the "other" category which denoted primarily the presence of a psychosomatic disorder. This implies that a good number of children attending a child psychiatric clinic in Africa arc brought because of functional complaints, such as abdominal pain, rather than primary behaviour symptoms. Such pain is generally perceived as reflecting an organic illness that requires medication from a doctor. Interpretations which stress the possible conflictual interpersonal origin of a functional symptom are not easily accepted l)y parents and teachers, although the power envious neighbours or relatives may have upon psychological function is readily seen by everyone. Thus, the psychiatrist who works only in a hospital setting is confronted with a cultural system which gives him privileged access to children with psychosomatic di.sorders but does not easily permit him to influence attitudes pertaining to the emotional needs of children in general. The data in this study
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clearly indicate that Ugandan children show symptoms comparable to those exhibited in developed countries although in Africa the symptoms are seen as mere forms of nuisance which require punishment by an adult. This was confirmed in the clinical interviews during which the teachers and parents were asked what other symptoms, not included in the symptom check list, their child showed. In response, both groups most commonly referred to a particular child's disrespect for his elders whom he was said to "abuse" verbally and to his unwillingness to perform the many duties even young children have in their homes. The latter problem was generally labelled "laziness" and was applied to children who occasionally refused to sweep the house and yard, help in the fields, collect firewood or prepare meals. The clinical diagnoses given to the problem school children appeared to reflect these sentiments by stressing the predominantly reactive nature of their problems (reactive behaviour disorders) or the children's deviant response to adolescence or other developmental milestones (healthy responses). It now seem important to follow up these leads and construct symptom check lists which incorporate items primarily meaningful in the African context. The extent to which these symptoms show themselves in various life situations is examined in the evaluation of factor scores obtained from the symptom check lists of parents and teachers. This in itself is a procedure not used by those who designed these scales initially and is fraught with obvious dangers. Nevertheless, as the author at the time of the actual data collection was ignorant of the parental scale which complements the teacher rating scale and makes an item comparison possible, he saw no other way of comparing the two different assessment measures. To what extent the fairly high concordance of factor scores obtained among parents and teachers truly reflects commonalities in the children's behaviour is difficult to determine. Some ofthe individual cells have very low frequencies. This reduces the weight one can give to the statistical findings and allows only very tentative interpretations. It appears, however, that the main discrepancy between the two scales stems from boys who are labelled neurotic by their parents and seen by their teachers as conduct disorders. The girls, on the other hand, are seen more often as neurotic by their teachers than their parents. An explanation of this finding is difficult but may be sought in the specific cultural situation. Girls in the Ugandan home are expected to be even more docile than boys. Hence any "abnormal behaviour" may only be able to go in the direction of self-assertiveness, viewed by the parents as "acting out". In contrast disturbances in the culturally more active boys may be perceived as increased withdrawal and shyness. As school authorities do not share these stereotyped sex role expectations, disturbances in this milieu may indeed take other forms. Turning to the reform school one finds the dehnquent boys showing a pattern similar to that ofthe school boys. Unfortunately, the housemasters of only 17 ofthe children completed the symptom check list as some of them were not familiar enough with the individual children (there were 25-30 children per housemaster) or had only recently been transferred to the particular group of youngsters. This may have lowered the statistical confidence of our findings in ihis group. As 10 out ofthe 20 neglected reform school youngsters had a normal teacher's symptom count and the housemasters rated 70% of them also within normal limits
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the remaining number of abnormal children was too small to be included in the factor comparison. Although teachers and parents agree significantly on the main focus of the child's disturbances, the clinical diagnosis shows less concordance with the symptom check list factors. This is especially true for the school children diagnosed as reactive behaviour disorders. Ofthe 26 school children so diagnosed, 10 had high parental neurotic scores, four high parental and teacher conduct scores and 12 had less pronounced symptom patterns. Likewise, four of seven conduct disorders had high conduct scores in both the teacher and parental scales. It is also interesting to note that the great majority of other diagnoses made by the author corresponded with the preponderance of neurotic symptoms on the parental check list. This may indicate that behaviour classified as "neurotic" in these symptom check lists in Africa represent a conglomerate of psychological maladjustments which are primarily characterized by an absence of acting out or anti-social behaviours. The child, nevertheless, may show these symptoms in response to stressful external events, developmental huidlcs or as an expression of functional physical complaints. The findings for both the delinquent and clinic groups are similar. In all but one child the housemasters rated the reform school children diagnosed as personality disorders high on the conduct factor and those seen as reactive behaviour disorders as either neurotic or low on both the conduct and neurotic factor. The clinic population showed similar trends. Ofthe eight children diagnosed as behaviour disorders four had a high neurotic score (above 10) while only one had a high conduct score. Other children with high neurotic scores were diagnosed as psychoneurotic (2 children) and psychosomatic disorders (3 children). Children from both the school and clinic populations who were diagnosed as essentially normal or merely physically ill, generally had a lower parental check list score than those given a positive psychiatric diagnosis (total score 9-8 vs 16-3). These results may be a reflection of the author's bias in unwittingly basing his diagnosis primarily on the account of the parents rather than the teachers. In the original data (Rutter et al., 1970, p. 174), about 40% of all parents whose children were given positive psychiatric diagnoses saw their children as having no more problems than most other children. In these data the parental check list scores also agreed most strongly with an overall measures of psychiatric disorder. The percentage of Ugandan parents who at the outset ofthe interview denied any problem in their children or saw none more serious than in most other children was somewhat lower (15 parents = 32%) than in Rutter's original data although five parents in the subsequent symptom enquiry reported a high number of abnormal behaviours. There were also four parents among the 48 controls who rated their children as disturbed. Two of these children were in fact diagnosed as behaviour disorders by the author while the other two were seen as normal. There were a further two control children who were diagnosed as adjustment reaction (healthy responses) who had not received a high score from their parents, making for a total false negative rate of about 8% among the controls. This would speak against an undue influence of the parental opinion upon the examiner's diagnostic choice but supports the possibility that Ugandan parents do know more about their children than teachers and are in fact willing to talk about these problems to an interested person. This possibility
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KLAUS K. MINDE
is supported by data presented in another paper (Minde, 1976) which documented that treatment suggestions made by the author or his assistants were wilUngly accepted and carried out weU by the families and teachers. In summary, it can be said that behavioural screening techniques developed in western countries yield a substantial number of school aged children in East Africa who upon close examination show psychiatric symptomatology both at home, at school and on clinical psychiatric examination. While some specific symptoms such as masturbation or bed-wetting are very rarely encountered in Uganda, the majority ofthe screening test items seem to possess transcultural relevance. This supports the increasing evidence (Rutter et aL, 1974) that familial risk factors associated with psychiatric disorders are valid in many cultures and that the behavioural expectations of school age children in Uganda and Britain are quite similar in terms of clinical practice. It also strongly suggested that child psychiatrists in order to have a true impact on the developmental needs of children in developing countries may need to combine hospital based chnic work with active community involvement as children with primary behaviour symptoms in Africa typically are not sent to hospitals but must be found and treated in the comn:iunity. SUMMARY A total survey of psychiatric symptoms of primary school children attending three schools in economically distinct areas of Uganda was made. The symptoms were compared with those displayed by primary school aged children committed to a reform school and patients attending a child psychiatric outpatient clinic in the same country. Results indicate that high and low scoring school children and reform school children have different family backgrounds. There was good correlation between parent and teachers in identifying disturbed youngsters and characteristic diagnostic patterns of school and clinic children. The significance of these findings is discussed in terms of the role child psychiatry may play in developing countries. Acknowledgements—This study was supported by East African Community Grant number 523513-006. I would also like to thank Mr. S. Kiwanuka, and all the headmasters and staff of Naguru, Kinseye and Lutete Primary Schools and Kampiringisa Reform School for their assistance and continuous support. REFERENCES ASUNI, T . (1970) Problems of child guidance ofthe Nigerian school child. W. Afric. J. Educ. 14,49-52. CEDERBLAD, M . (1968) A child psychiatric study on Sudanese Arab children. Acta Psychiat. Scand. Suppl. 200. GAP (1966) Psychopathol(^ical disorders in childhood: theoretical considerations and a proposed classification. Croup for the Advancement of Psychiatry, Vol. VI, Report No. 62. GERMAN, G . A. (1972) Aspects of clinical psychiatry in sub-Saharan Africa. Br. J. Psychiat. 121, 461479. GIEL, R . and VANLUIJK, J. N. (1969) Psychiatric morbidity in a small Ethiopian town. Br. J. Psychiat. 115, 149-162. GiEL, R., BiSHAW, M. and VANLUIJK, J. N. (1969) Behaviour disorders in Ethiopian children. Psychiat. Neurol. Neurochir. 72, 395-400. GOODALL, J. (1972) Emotionally induced illness in East African children. E. Afric. Med. J . 49,407-412.
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HOLLINGSHEAD, A. and REDLICH, R . F . (1958) Social Class and Mental Illness. A Community Study. Wiley, New York. IZUORA, G . E . A. (1970) Mental health of children in developing countries. Proceedings 2nd PanAfrican Psychiatric Workshop, p. 59. Mauritius. LEIOHTON, A . H . , LAMBO, T . A., HUGHES, C . C , LEIGHTON, D . C , MURPHY, J. M. and MACKLIN,
D. B. (1963) Psychiatric Disorder Among tlie Toruba. Cornell University Press, Ithaca. N.Y. MBANEFO, S. E . (1971) The general practitioner and psychiatry. In Psychiatry and Mental Health Care in Ceneral Practice. University of Ibadan, Department of Psychiatry and Neurology. MINDE, K . (1974) The first 100 cases of a child psychiatric clinic in Uganda: a follow-up investigation. East Afric. J. Med. Res. 1, 95-108. MINDE, K . (1975) Psychological problems in Ugandan school children: a controlled evaluation. J. Child Psychol. Psychiat. 16, 49-59. MINDE, K . (1976) Child psychiatry in developing countries: some lessons learned. East Afric. J. Med. Res. (in press). NURCOMBE, B. and CAWTE, J. E. (1967) Patterns of behaviour disorder amongst the children of an aboriginal population. Anst. NZ- J- Psychiat. 1, 119-133. PiiTERsoN, P. R. and QUAY, H . C . (1967) Factor analyzed problem checklist. University of Illinois, Children's Research Center, Urbana, IL. RAHIM, T. H . (1972) Psychiatric disorders in the Red Sea children. Paper presented at the Zrd PanAfrican Psychiatric Congress, Khartoum, November. RUTTER, M . (1967) A children's behaviour questionnaire for completion by teachers: preliminary findings. J . Child Psychol. Psychiat. 8, 1-11. RUTTER, M.,TIZARD, J. and WHITMORE.K. (1970) ^tfuci/r/onj/Zea/Z/tanrfBeAflWow^ Longmans, London. RUTTER, M . (1971) Parent-child separation: psychological effects on the children. J. Child Psychol. Psychiat. 12, 233-260. RUTTER, M . , YULE, W . , BERGER, M . , YULE, B., MORTON, J. and BAGLEY, C . (1974) Children of
West Indian Immigrants—I. Rates of behavioural deviance and of psychiatric disorder. J. Child Psychol. Psvchiat. 15, 241-262.
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