Acta psychiat. scand. (1976) 54, 29-42 Institute of Psychiatric Demography (Head: A. Dupont, M.D.), Risskov, Denmark
Psychic disorders among pre-school children in a geographically delimited area of Aarhus county, Denmark AN EPIDEMIOLOGICAL STUDY
A study was undertaken concerning prevalence of psychic disorders among 175 5- to 6-year-old, pre-school children randomly selected from the general population in the municipality of Aarhus and the island Sam@ of Aarhus County, Denmark. Deviant behaviour was arbitrarily defined, with a symptom considered aberrant if it occurred in 10 % or less of the children studied. Mental health of the children was assessed by (a) the number of deviant symptoms, (b) opinions of the parents and (c) the personal assessment of the author, who interviewed all the families. Thirty-five probands (20 %) showed good adjustment, 113 (65 %) were coping well with only minor symptoms, and 27 children (15 %) were poorly adjusted. A high prevalence of psychosomatic, behavioural, and emotional symptoms was observed, some of them more frequently among boys than girls. No significant difference was found between urban and rural children. The need for psychiatric help even among supposedly normal, pre-school children is discussed and emphasized. Key words: Epidemiology - behaviour disorders - psychiatric treat-
ment - pre-school age.
Epidemiological studies of behaviour disorders in children have been carried out from diverse approaches, seemingly due to the ambiguity as to the nature of these disorders, their prevalence, prognosis, and aetiology. Traditionally, psychiatrists have tended to focus their attention on children already attending psychiatric clinics (Dahl (1970), Baldwin (1968), Sundby et al. (1968)). These, however, constitute only a minor fraction of the psychically disturbed children, as has been pointed out by Rutter et al. (1970) and Shepherd et al. (1971). Disorders exhibited by such children raise the question of the probable distribution of similar symptoms in the overall child population, normal or otherwise, and not under psychiatric care. In other words, despite its importance, few attempts have been made to evaluate the problem of psychic disorders among children in its entirety. Prevalence studies have more commonly been concerned with symptoms or behaviour patterns rather than a consideration of whether these characteristics truly indicate psychiatric disorder. Of several such studies, the work of Macfarlane et al. (1962) deserves special mention. They studied a group of children ranging
30
in age from 21 months to 14 years, employing standardized criteria based on the frequency and intensity of symptoms, achieving uniform data about behavioural patterns. Rutter et al. (1970) surveyed the prevalence and nature of handicaps among 9- to 11-year-old children on the Isle of Wight with the ultimate aim of planning services to meet the needs of such chiIdren. The study of Shepherd et al. (1971) of representative British school children between the ages of 5 and 15 had a daerent aim, namely an assessment of mental health. This was achieved by estimating the extent of behaviour disorders in a presumed normal population. A similar approach was that of Jonsson & Kalvesten (1964) in their extensive social-psychiatric study of the school-boys of Stockholm. An epidemiological study of behaviour characteristics of representative Danish children of the pre-school age, between 5 and 6 years, forms the subject matter of this report. A particular aim of this survey was to analyse the frequency and intensity of behavioural andlor emotional problems among such children in order to assess the need for psychiatric or psychological care. Special attention was paid to methodology and data collection to enable comparison with similar studies undertaken elsewhere. METHODOLOGICAL CONSIDERATIONS Considerations governing the design of a survey of child symptomatology are manifold - extensity or intensity, longitudinal versus cross-sectional, sampling as opposed to a comprehensive survey of a population - to mention only a few. Extensive surveys, in contrast to intensive ones, comprise a great number of probands leading to a better quantification of the data. Though more efficient in time and money, they rarely yield in-depth knowledge of the individual proband. A combination of the two methods has evident advantages especially when employed consecutively so that a representative sample of the extensive survey is the material of choice for the later, intensive survey. Longitudinal and cross-sectional surveys lead to different approaches of the frequency of psychic disorders, namely incidence and prevalence, respectively. Continuity of data collection is the prime advantage of a prospective longitudinal inquiry. It is of particular value in investigations of children as it enables a better study of the alternating development of the individual child and may elicit factors controlling the disease. Cross-sectional studies differ in many ways from prospective ones. They are more efficient and allow sequential analyses of the data, and a more representative sampling can be achieved in view of the limited loss. In short, prospective and cross-sectional studies are complementary rather than mutually exclusive. Prospective surveys have their advantage in studies of children’s motor, intellectual, and psychological development. In child psychiatric research, they provide a deeper insight into psychopathological mechanisms, helping to ascertain whether digressions only occur as transient phenomena in essentially normal children and also in the prognosis of certain disorders. Cross-sectional studies, on the other hand, are preferred for surveying large populations for estimating the prevalence of psychiatric disorders in order to plan for future services.
31 In both methods, the size of the sample is of crucial importance. Surveys covering entire population groups are naturally the best but some sort of sampling is generally inevitable if considerable amounts of information are to be collected economically. The utility of using a sampling technique depends on the representativeness of the sample and the completeness with which it is included in the study.
MATERIALS AND METHODS The sample The present study was conducted as a cross-sectional survey of two groups of pre-school children resident in two mGicipalities within Aarhus County, namely the municipality of Aarhus and the island of Samsgi. On April 1, 1974, the county of Aarhus had a population of 556,647. Of these, 245,660 were residents in the municipality of Aarhus, a highly urbanized, densely populated region and the second largest town in Denmark. Sam@ is a typically rural district and had 4,885 inhabitants on April 1, 1974. The material of the Aarhus investigation comprised a random sample of children born between January l and December 31, 1968, and residing in the municipality of Aarhus on November 1, 1973. The municipal school administration has a card index of all children of the municipality born in 1968, and the investigated sample was drawn randomly from these 3,574 children. The Aarhus sample consisted of 125 probands. The material of the Sam@ investigation was obtained from the Institute of Psychiatric Demography of the Aarhus Psychiatric Hospital and comprises all children born between January 1 and December 31, 1968, and residing on the island on April 1, 1974. This sample consisted of 58 probands, the total material of the investigation thus comprising 183 probands. Children under institutional care outside the investigated areas but with families residing in the areas are not included in the study. Pre-school children are primarily institutionalized due to mental retardation, and as that is the case in .l-.2 % (Bernsen (1976)) omission of this group cannot have influenced the results. Screening methods Three possible sources of information concerning the symptoms of the children were available: the health authorities, the children themselves, and their parents. Relying solely on hospital admission data has serious limitations from an epidemiological point of view due to their selective nature. Using children of preschool age as the main source of information was also considered inappropriate due to theoretical as well as practical drawbacks. Parents’ reports were thus found to be the most valuable source of information, even though several studies (Chess et al. (1966), Robins (1970)) have stressed that they lack sufficient reliability and may introduce bias in the results. The classical Scandinavian studies were based upon clinical, non-standardized interviews. A similar procedure was found less valuable in the present study,
32 in view of the aim to study as comprehensive a picture of the child‘s mental and physical health as possible in order to allow an overall assessment. In the light of the questionnaires of Macfarlane et al. (1962), Jonsson & Kalvesten (1964), Rutter et al. (1970), and Shepherd et al. (1971), a standard form was drawn up. A pilot study of 11 interviews was carried out to clarify the questions. The final form consisted of 128 queries concerning the family and its social background and prenatal and perinatal circumstances, development, previous diseases, current physical health, abilities, behavioural and emotional symptoms of the child in question. Procedure Prior to the interviews an explanatory letter was sent to the 183 families involved, including those who during the period November 1, 1973 to the time of the investigation had moved away from the municipality of Aarhus. In the Aarhus investigation, 119 of the 125 families selected were induced to participate and personally interviewed by the author. Of the remaining six, two had emigrated from the country, and four were unwilling to cooperate, On Samspr, 56 of the 58 families agreed to participate. No information was available about the two families who had emigrated. The six non-cooperating families all expressed pronounced aversion towards any intrusion into their private life, four giving former conflict with authorities or institutions as the underlying reason. The total participants of the investigation comprised thus 95 boys and 80 girls, corresponding to 95.6 % of the original material. Interviews were aIways carried out in the child‘s home in the presence of one or both parents. Despite an effort to involve the fathers, mothers’ reports played an overwhelming role in the completion of the form. In only three cases did fathers’ reports provide the basis for completing the questionnaires. A personal contact was established with the children, and their behaviour and reactions were observed as well as the parent-child relationship. This information was subsequently supplemented in various ways. In the Aarhus investigation, inquiries were made about hospital admissions and attendance at the prophylactic health controls to the general practitioner (G.P.). On Samspr the survey was of a more intensive nature. A Vieland Test was carried out and parents were questioned about their own physical and mental health. Information from other sources was obtained in the following ways: 1. In collaboration with one of the two G.P.’s on the island all the files concerning the families involved were perused. 2. The families’ contact, if any, with the psychiatric clinic on the island was examined. 3. The health visitor, the social worker, and the family consultant on the island provided supplementary information about the social background of the families.
33
Table 1. The interviewed probands distributed according to sex and place of residence Girls
Boys
Total
abs.
%
abs.
%
Aarhus
67
56.3
52
43.7
119
SaIns@
28
50.0
28
50.0
56
Total
95
54.3
80
45.7
175
The greater intensity of the survey on Sam@ made it possible to give a more comprehensive picture of the attitude of the parents and the social and cultural setting. In the present report, however, only data comparable to data from the Aarhus-survey are represented. Collected data were transferred to punchcards sorted according to the child’s identification number. Quantitative analysis was carried out employing the SPSSsystem (Statistical Package for the Social Sciences, Nie et al. (1975)). The reported significant differences refer to results of X2-tests or, where appropriate, Fisher’s exact test. RESULTS Table 1 shows the distribution of the investigated material according to place of residence and sex. The total profile of the child’s behaviour was divided into four categories, based on symptoms concerning 1. biological functions and motor manifestations, 2. social adaptation, 3. structure of the personality, and 4. current abilities.
On the basis of the parents’ reports, a high prevalence of psychosomatic and behavioural symptoms was found. Table 2 presents the prevalence of selected symptoms concerning biological functions and motor manifestations according to sex and place of residence. It varies considerably, with about 20 % reporting pains in the stomach once a week or more, to 2 % reporting encopresis once a week or more. Table 3 shows the prevalence of antisocial behaviour according to sex and place of residence. Table 4 presents the prevalence of selected behaviour characteristics according to sex and place of residence. From the parents’ reports it appeared that more than 20 % of the children were excessively shy and reserved, moody, worried, ambitious, dominating, wanting to attract attention, or showing frequent loss of temper. Between 10 and 20 % of the subjects were said to be 3 ACTA PSYCH 542
34
Table 2. The prevalence of various symptoms concerning biological maturation distributed according to sex and place of residence
Aarhus
samsz
Total
(%I
(%I
(%I
Symptoms
Stomach-ache Headache Speech disorders Enuresis nocturna Encopresis Nail-biting Thumb-sucking Nightmares Tics
Boys
Girls
Boys
22 4 12 12 3 19 7 13 13
17 6 2 10 2 17 10 6 6 n=52
11 7 32 21 4 7 18
n = 67
4
14 n=28
Girls
Boys
Girls
4 4 7 7 4 14 14 4 4 n=28
19 5 18 15 3 16 11 11 14 n=95
12 5
4 9 3 16 11 5 5 n=80
Table 3. The prevalence of antisocial behaviour distributed according to sex and place of residence
Aarhus
samsz
Total
(%I
(%I
(%I
Symptoms Boys Stealing Lying Truancy Interest in fire Firesetting
3 10 1 22 3 n=67
Girls 0 6 2 9 2
n=52
Boys 4 0 4 25 7 n=28
Girls 0 4 0 7 0 n=28
Boys
Girls
3 7 2 23 4 n=95
0 5 1 9 1 n=80
excessively disobedient, submissive, destructive, aggressive, and lacking in concentration. Excessive jealousy, selfishness, day-dreaming, avoiding attention, fear of new situations or things, and difficulties in establishing contacts were found among 5 to 10 % of the children. Table 5 presents various developmental abilities according to sex and place of residence. An analysis of the overall differences between the urban and the rural sample shows only a slight difference in the behaviour characteristics of the two. Stomach-ache was thus the only symptom reported with a significantly greater frequency ( P = 0.005) in the Aarhus than in the Sam@ sample. An analysis of the present findings in terms of sex differences shows that boys had more problems than girls. No symptom was observed with a significantly greater frequency among girls whereas several symptoms were found more frequently among boys. As shown in Table 6, differences between the sexes were significant in respect of excessive ambition, disobedience, aggressiveness, speech disorders, changes of mood, clumsiness, interest in fire together
35 Table 4. The prevalence of various behaviour characteristics distributed according to sex and place of residence ~
Aarhus
Sams#
(%I
(%)
Behaviour
of temper Mood swings Restlessness Aggressiveness Submissiveness Destructiveness Difficulty in establishing contacts Jealousy Fears Disobedience Day-dreaming Selfishness Dependency (fear of separation) LOSS
_
_
_
_
Total
Boys
Girls
Boys
Girls
Boys
Girls
39 34 27 18 18 13
40 15 17 12 13 12
50
25 25 18 11 14
54 14 18 0 14 4
42 32 26 18 16 14
45 15 18 8 14 9
12 6 4 27 7 13
6 12 8 8 4 2
14 11 0 18 0 7
4 11 0 0 7 11
13 7 3 24 5 12
5 11 5 5
12
17 n = 52
11 n = 28
14
n = 67
n = 28
12 n=95
16 n=80
5 5
Table 5 . The prevalence of the present developmental abilities distributed according to sex and place of residence Aarhus
Sam@
Total
1%)
(%I
(%)
Ability Boys Unable to dress by himself Unable to handle knife (or fork or spoon) Not counting up to 10 Not knowing any letters
Girls
Boys
Girls
7
4
25
4
30(1) 3 12 n=67
29(0) 4 6 n=52
89(0) 14 25 n=28
71(0) 0 7 n=28
Boys
12 47(1) 6 16 n=95
Girls
4 44(0) 3 6 n=80
Table 6. The prevalence of various behavioural items showing significant sex differences distributed according to sex Behaviour Excessive ambition Mood swings Disobedience Interest in fire Clumsiness Speech disorders Aggressiveness
3'
Boys
Girls
(%I
(%I
47 32 24 23 19 18 18 n = 95
24 15 5 9 6 4 8 n = 80
Total
37 x2 = 10.44 P < 0.005 24 xa = 6.54 P < 0.025 15 x2 = 12.28 P < O.OOO5 17 x' = 6.52 P < 0.025 13 x'= 6.13 P < 0.025 11 x' = 8.58 P < 0.005 13 x2 = 4.11 P < 0.05 n = 175
36 Table 7. The retation between symptom load and the investigator‘s as well as the parents’ assessment of the child Symptom load
0-3 Investigator’s assessment* No behaviour problems Behaviour problems Parents’ assessment** No behaviour probIems Behaviour problems
129
2 4
24
4 18
122 31
13 9
* x2 = 46.12, P < 0.001. ** f = 4.65, P < 0.05.
Symptom load
Fig. 1. The material distributed according to “symptom load” and sex (n = 175).
37
with current developmental abilities. There were also marked, but not significant, differences in respect of restlessness, stealing, destructiveness, truancy, selfishness, attraction of attention, tics, nightmares, enuresis nocturna, difficulties with others, and stomach-ache. It is well known (Kunner (1960), Lapouse & Monk (1964)) that the early childhood years are characterized by a variety of emotional and behavioural disorders. These disorders do not constitute disease entities deviating qualitatively from normality as unambiguous criteria for normal behaviour in pre-school childrsn are lacking. Consequently, there is considerable doubt as to the psychopathological significance of such behaviour. In the present study, though each type of behaviour was analysed separately, the need to develop a method for measuring the overall deviance was not overlooked. A statistical delimitation, though it is easy to handle and avoids conceptual problems, has the disadvantage of equating normality with frequent presence, while ignoring the aetiology and prognosis of the various symptoms. Despite methodological disadvantages, it was decided to use the statistical approach in assessing the extent of psychic disorders. Accordingly, any type of behaviour which occurred among 10 % or fewer children was defined as deviant. A score for the total deviance, the “symptom load”, was constructed as follows: The different items were all given the same weight and the child received one point for each deviation. Thirty-seven behaviour characteristics of the standard scheme were reported in 10 % or fewer of the children and consequently the “symptom load” could range from 0 to 37. From Fig. 1, it appears that 101 probands (58 %) had a symptom load of less than 2, symptom loads ranging from 2 to 4 were seen in 58 probands (33 %), and the remaining 16 probands (9 %) presented a deviation of 5 points or more. Besides describing behavioural characteristics, an attempt was also made to elucidate the underlying patterns of association. To investigate clustering of the symptoms, a factor analysis was carried out, based on correlation matrices of the 37 variables constituting the symptom load. The “eigenvalues”, i.e. the fraction of the total variance explained by each factor, were calculated. As a result, 15 factors appeared explaining 67 % of the total variance. On the basis of these data, underlying syndromes or clustering of symptoms could not be determined. The number of maladjusted children was assessed by two methods. Parents were asked to state whether their children were disturbed at the time of the investigation or had been so formerly. It was found that 12 % of the children exhibited behavioural or emotional symptoms at the time of the investigation whereas 11 % had done so previously. Alternatively, the interviewer gave a clinical evaluation of the mental health of the children and found 8 % of the children to have psychiatric disorders and a further 15 % to have minor behavioural or emotional problems. Subsequently, the interrelation between the three different assessments was analysed. It was found (Table 7) that the presence of a symptom load of 4
38 Table 8. The relation between the investigator’s and the parents‘ assessment of the child
Parents’ assessment
Investigator’s assessment behaviour
Behaviour problems
110
25
23
17
No
problems
No behaviour problems
Behaviour problems
y = 9.73,P < 0.01. points or more was significantly related to the parents’ assessment (P < 0.05) as well as the investigator’s assessment (P< 0.01) of the child as disturbed. In addition, the interrelation between the parents’ and the investigator’s assessment was also found to be significant (P < 0.01) (Table 8). On the basis of the three different judgements it was possible to assess the current state of the mental health of the children. Thirty-five probands (20 %) showed good adjustment without behavioural or psychosomatic troubIes. A total of 113 probands (65 %) did well with only minor symptoms. Of these, 74 were found to be undisturbed through these three assessments. The remaining 39 probands, though disturbed in at least one assessment, still showed fair adjustment. Twenty-seven probands, corresponding to 15 %, were poorly adjusted. This group consisted of two subgroups, one comprising the 19 probands found disturbed by the investigator and through one of the other assessments, and the other comprised the eight probands assessed as disturbed through all three methods. The relation between the children’s symptoms and various demographic variables was examined. Social background was assessed by classifying the fathers’ occupations according to the Svalastoga Scale (Svalastoga & Wolf (1969)) and by estimating the annual income of the family. The social setting assessed in these ways was not clearly associated with the child’s adjustment. A variable “social risk” was constructed comprising the following items: born out of wedlock, grown up in a broken home, prolonged stay away from home, death of the parents, not having been brought up by the biological parents, low age of the father, poor economical conditions, unsatisfactory housing. A significant relation (P < 0.05) was observed between a low social risk and a well-adjusted child according to the investigator’s assessment. Housing conditions were examined in terms of sanitation, sleeping facilities, number of rooms, and a garden. These conditions were not found to be related to the child’s deviance. Size of the family seemed of minor importance for the child’s mental health.
39 On the other hand, while older children had higher symptom loads, the youngest children exhibited this condition to a lesser degree than expected. An analysis of the family conditions showed that children from broken homes as well as children not brought up by their biological parents had a significantly higher symptom load. By analogy with “social risk”, a variable “medical risk” was formulated with the following items: pathological pregnancy, very young mothers, birth weight I 2,500 g, complicated delivery, prenatal and perinatal complications. Presence of a high medical risk was related neither to the social background nor to the child’s behaviour problems. About one fourth of the children had been admitted to hospitals on one or more occasions, but the immediate effect of this on the children’s mental health could not be estimated. At the time of the investigation, such admissions seemed to have no relation to the behaviour problems. Severe physical disorders were rarely recorded and apart from a couple of asthmatic cases, no child appeared to have or have had disabling somatic disorders. DISCUSSION The present study was undertaken to assess the extent of psychic disorders among randomly selected children of pre-school age, in order to provide some basis for planning future child psychiatric services in Denmark. As used here, the term “psychic disorder” refers to a condition or behaviour of the child deviant from that expected for his age group, involving suf€ering andlor distress, causing concern to his parents. About 15 % of the children studied were found to have psychic disorders. Unfortunately, about one third of the parents of this group were ignorant and unaware of this fact. In the remainder, though aware of the problem, the parents had not taken the trouble to have their children treated at the local paediatric, child-psychiatric, or child guidance clinics. Underlying reasons for this indifference are many. Some parents were unaware of the local treatment facilities. Some were sceptical as to the desirability of treating psychic disorders, postponing such action until the disorder became a problem. A general feeling that the G.P. should not be troubled with such cases, coupled with a lack of confidence in his professional competence to handle such ailments (an attitude also common in the medical profession), has compounded the problem. COMPARISON WITH OTHER STUDIES Ambiguity concerning the definitions of behaviour disorders of children and the lack of precise frames of reference for the individual symptoms made a comparison of the present findings with those of others difficult. In some studies, even the frequency and intensity of the symptoms encountered are not clearly stated. Danish prevalence studies are also characterized by their diversity of approach. Thus Heinild (1969, 1972) analysed the children treated by a socialpaediatric out-patient clinic, and estimated that only 2 to 4 % of the children
40 in Copenhagen showed errant behaviour. Severe maladjustment and developmental disorders were observed in 5 to 10 % of the 9- to 11-year-old children studied by Vedel-Petersen et a2. (1968), who believed this figure to be an underestimate. According to Helbo (1967, 1972), 26 % of rural children starting school showed reactive symptoms, while one third of all school children studied had psycho-social problems requiring treatment. These are, perhaps, exaggerated evaluations as he classified children with even minor tension phenomena as needing treatment. In contrast, Lunge (1974) reported that about 16 % of 10-year-olds on Samso needed psychiatric help. Even surveys conducted under comparable conditions led to varying conclusions. Behavioural deviances ranging between 13 and 63 %, with 5 to 14 % of the children needing specialist treatment, were recorded by the Swedish 4-year Health Controls (Holst et al. (1970), Goteborgsforsoket (1972), Kiihler (1973)). In this study, a number of symptoms appeared to be more prevalent among boys than among girls. A similar, albeit insignificant, preponderance of psychically disturbed boys was deduced from the analyses of mental health by the three modes of assessment. Predominance of boys among psychically maladjusted children has also been reported by others (Rutter et al. (1970), Chazan & Jackson (1971), Shepherd et al. (1971), Werry & Quay (1971)). Besides a greater number of symptoms, boys frequently manifest traits, causing their parents to seek treatment of them (Wolf7 (1961), Dahl (1970), Hjermind (1971)). Lack of close correlation between social background and psychic problems of children observed in this study is in accordance with the findings of Jonsson & Kalvesten (1964), Lapouse & Monk (1964) and Shepherd et al. (1971). HOWing conditions, too, are seemingly unrelated to the psychic disorders, though further studies, similar to the Stockholm Suburban Project of Tengvald et at. (1974) are warranted to elucidate the influence of modem housing on the psycho-social behaviour of children. IMPLICATIONS FOR FUTURE PSYCHIATRIC SERVICES In this study, no child showed symptoms of a severity demanding immediate admission as an in-patient, but many exhibited less severe disorders. The desirability of treating such cases has been much discussed. According to Lapouse & Monk (1964), deviant behaviour has no pathological significance. A majority of emotional disturbances are said to recede spontaneously (Shepherd et al. (1971)). Contrariwise, others favour treatment of even minor disorders (Jonsson & Kiilvesten (1964), Helbo (1969, 1972)). Prevention is undoubtedly better than cure in terms of suffering, hence, it is unfortunate that disorders considered not severe or serious go undetected and untreated due to the inadequacy of the existing services. Child psychologists and psychiatrists ought to extend their extramural activities and functions as advisors to G.P.’s, health visitors, social workers, and educationists. Even for severe forms of behaviour problems that may recede spontaneously, treatment to shorten their duration is obviously justified and desirable. The duration and clinical significance of these disturbances seem to be correlated not only with
41 their severity but also the setting in which they occur. Of crucial importance is the attitude of parents, who in turn are influenced by social and cultural conditions about which little is known at present. Some disturbed children receive professional assistance; others do not. Why? Equally fragmentary is our knowledge regarding the efficacy of early psychiatric treatment or preventive mental hygiene through a systematic campaign of information. On the other hand, planning and restructuring of future service cannot wait upon such results. Urgent problems require action now. “But the development of services must be planned in such a way that research is built-in to the development in order that planners in the future can know which steps have been effective and which have not. In the absence of research we can only move forward blindly, able to profit neither from our mistakes nor from our successes’’ (Rutter et al. (1970)).
ACKNOWLEDGEMENTS I wish to thank Annelise Dupont, M.D. and the staff of the Institute of Psychiatric Demography, especially Mrs B. Kaldau and Mrs E. Henriksen. I also wish to thank the participating general practitioners, especially T. Bi(rn-Henriksen, M.D., Sam@. REFERENCES Psychiatric illness from birth to maturity: an epidemiological Baldwin, J . A . (1968): study. Acta psychiat. scand. 44, 313-333. Bernsen, A. (1976): Severe mental retardation among children in the county of Aarhus. Acta psychiat. scand. 54, 43-66. Chazan,M., & S. Jackson (1971): Behaviour problems in the infant school. J. Child Psychol. 12, 191-210. Chess, S., A. Thomas & H . Birch (1966): Distortions in developmental reporting made by parents of behaviorally disturbed children. J. Amer. Acad. Child Psychiat. 5, 226-234. Dahl, V. (1970): Et 5 Qrs materiale fra et ridgivningscenter (A 5-year study in a child guidance clinic). Ugeskr. Lzeg. 132, 1169-1175. Goteborgsforsoket med halsokontroll av fyrairingar (Health control of 4-year-olds) (1972): Liikartidningen 69, 1893-1919. Heinild, S. (1969): Social padiatri (Social pediatrics). Ugeskr. Lag. 131, 1901-1911. Heinild, S. (1972): Samspilsramte b@m (Multiproblem families). Minedsskr. prakt. hgegern. 49, 273-302. Helbo, S. (1967): Bfirneproblemer p l landet (Problems of rural children). Ugeskr. h g . 129, 171-174. Helbo, S. (1972): Skolesundhedspleje p l familiebasis (School health work on familial basis). Ugeskr. b g . 134, 1619-1622. Hjermind, E . (1971): De praktiske behandlingsmuligheder for psykisk svaert lidende bfirn (The practical therapeutic possibilities for children with severe mental disturbances). Ugeskr. h g . 133, 1269-1274. Holst, K., E. M . Kohler & L. Kohler (1970): Dalbyundersokningarna: Undersokningar av 4-iringar. (Dalby investigations: Investigations of 4-year-olds). Liikartidningen 67, 3673-3677. Jonsson, G., & A . L. Kiilvesten (1964): 222 Stockholmspojkar (222 boys from Stockholm). Almqvist & Wiksell, Uppsala. Kanner, L. (1960): Do behavioural symptoms always indicate psychopathology? J. Child Psychol. I, 17-25. I
42 Kohler, L. (1973): Health control of four-year-old children. An epidemiological study of child health. Acta paediat. scand., Suppl. 235. Lunge, B. (1974):Personal communication. Lapouse, R., & M . Monk (1964): Behaviour deviations in a representative sample of children. Amer. J. Orthopsychiat. 34, 43-46. Macfarlane, J . W., L . Allan & M . P. Honzik (1962): A developmental study of the behaviour problems of normal children between 21 months and 14 years, 2nd ed. University of California Press, Berkeley, Los Angeles. Nle, N . H., C. H . Hull, I . G . Jenkins, K . Steinbrenner & D . H. Bent (1975): Statistical package for the social sciences. 2nd ed. McGraw-Hill, New York. Robins,L. N . (1970):Follow-up studies investigating childhood disorders. In Hare, E. H., & 1. K . Wing: Psychiatric epidemiology. Oxford University Press, Oxford. Rutter, M., J. Tizard & K . Whitmore (1970): Education, health and behaviour. Longman, London. Shepherd, M.. B. Oppenheim & S. Mitchell (1971): Childhood behaviour and mental health. University of London Press, London. Sundby,P., H . Sommershild & P. C. Kreyberg (1968): Prognosis in child psychiatry. Universitetsforlaget, Oslo and Williams & Wilkins, Baltimore. Svalastoga, K., & P. Wolf (1969): Social rang og mobilitet (Social rank and mobility), 2nd ed. Gyldendal, Copenhagen. Tengvald, K., B. Lagerkvist, S. Lauritzen & P. Olin (1974): Fyrasringar i en ny forort (Four-year-olds in a new suburb). Socialmed. T. 51, 9!?-104. Vedel-Petersen, J., A . From, T . LQve & I . MQrk Petersen (1968): Bflrns opviekstvilkik (The conditions of upbringing). Socialforskningsinstituttets publikationer, No. 34, Copenhagen. Werry, J . S., & H . C . Quay (1971): The prevalence of behaviour symptoms in young elementary school children. h e r . I. Orthopsychiat. 41, 136-143. Wolff,S. (1961): Social and family background of pre-schml children with behaviour disorders attending a child guidance clinic. J. Child Psychol. 2, 260-268.
Received March 23, 1976
Marianne Kastrup, M.D. Institute of Psychiatric Demography 8240 Risskov Denmark
Psychic disorders among pre-school children in a geographically delimited area of Aarhus county, Denmark AN EPIDEMIOLOGICAL STUDY
A study was undertaken concerning prevalence of psychic disorders among 175 5- to 6-year-old, pre-school children randomly selected from the general population in the municipality of Aarhus and the island Sam@ of Aarhus County, Denmark. Deviant behaviour was arbitrarily defined, with a symptom considered aberrant if it occurred in 10 % or less of the children studied. Mental health of the children was assessed by (a) the number of deviant symptoms, (b) opinions of the parents and (c) the personal assessment of the author, who interviewed all the families. Thirty-five probands (20 %) showed good adjustment, 113 (65 %) were coping well with only minor symptoms, and 27 children (15 %) were poorly adjusted. A high prevalence of psychosomatic, behavioural, and emotional symptoms was observed, some of them more frequently among boys than girls. No significant difference was found between urban and rural children. The need for psychiatric help even among supposedly normal, pre-school children is discussed and emphasized. Key words: Epidemiology - behaviour disorders - psychiatric treat-
ment - pre-school age.
Epidemiological studies of behaviour disorders in children have been carried out from diverse approaches, seemingly due to the ambiguity as to the nature of these disorders, their prevalence, prognosis, and aetiology. Traditionally, psychiatrists have tended to focus their attention on children already attending psychiatric clinics (Dahl (1970), Baldwin (1968), Sundby et al. (1968)). These, however, constitute only a minor fraction of the psychically disturbed children, as has been pointed out by Rutter et al. (1970) and Shepherd et al. (1971). Disorders exhibited by such children raise the question of the probable distribution of similar symptoms in the overall child population, normal or otherwise, and not under psychiatric care. In other words, despite its importance, few attempts have been made to evaluate the problem of psychic disorders among children in its entirety. Prevalence studies have more commonly been concerned with symptoms or behaviour patterns rather than a consideration of whether these characteristics truly indicate psychiatric disorder. Of several such studies, the work of Macfarlane et al. (1962) deserves special mention. They studied a group of children ranging
30
in age from 21 months to 14 years, employing standardized criteria based on the frequency and intensity of symptoms, achieving uniform data about behavioural patterns. Rutter et al. (1970) surveyed the prevalence and nature of handicaps among 9- to 11-year-old children on the Isle of Wight with the ultimate aim of planning services to meet the needs of such chiIdren. The study of Shepherd et al. (1971) of representative British school children between the ages of 5 and 15 had a daerent aim, namely an assessment of mental health. This was achieved by estimating the extent of behaviour disorders in a presumed normal population. A similar approach was that of Jonsson & Kalvesten (1964) in their extensive social-psychiatric study of the school-boys of Stockholm. An epidemiological study of behaviour characteristics of representative Danish children of the pre-school age, between 5 and 6 years, forms the subject matter of this report. A particular aim of this survey was to analyse the frequency and intensity of behavioural andlor emotional problems among such children in order to assess the need for psychiatric or psychological care. Special attention was paid to methodology and data collection to enable comparison with similar studies undertaken elsewhere. METHODOLOGICAL CONSIDERATIONS Considerations governing the design of a survey of child symptomatology are manifold - extensity or intensity, longitudinal versus cross-sectional, sampling as opposed to a comprehensive survey of a population - to mention only a few. Extensive surveys, in contrast to intensive ones, comprise a great number of probands leading to a better quantification of the data. Though more efficient in time and money, they rarely yield in-depth knowledge of the individual proband. A combination of the two methods has evident advantages especially when employed consecutively so that a representative sample of the extensive survey is the material of choice for the later, intensive survey. Longitudinal and cross-sectional surveys lead to different approaches of the frequency of psychic disorders, namely incidence and prevalence, respectively. Continuity of data collection is the prime advantage of a prospective longitudinal inquiry. It is of particular value in investigations of children as it enables a better study of the alternating development of the individual child and may elicit factors controlling the disease. Cross-sectional studies differ in many ways from prospective ones. They are more efficient and allow sequential analyses of the data, and a more representative sampling can be achieved in view of the limited loss. In short, prospective and cross-sectional studies are complementary rather than mutually exclusive. Prospective surveys have their advantage in studies of children’s motor, intellectual, and psychological development. In child psychiatric research, they provide a deeper insight into psychopathological mechanisms, helping to ascertain whether digressions only occur as transient phenomena in essentially normal children and also in the prognosis of certain disorders. Cross-sectional studies, on the other hand, are preferred for surveying large populations for estimating the prevalence of psychiatric disorders in order to plan for future services.
31 In both methods, the size of the sample is of crucial importance. Surveys covering entire population groups are naturally the best but some sort of sampling is generally inevitable if considerable amounts of information are to be collected economically. The utility of using a sampling technique depends on the representativeness of the sample and the completeness with which it is included in the study.
MATERIALS AND METHODS The sample The present study was conducted as a cross-sectional survey of two groups of pre-school children resident in two mGicipalities within Aarhus County, namely the municipality of Aarhus and the island of Samsgi. On April 1, 1974, the county of Aarhus had a population of 556,647. Of these, 245,660 were residents in the municipality of Aarhus, a highly urbanized, densely populated region and the second largest town in Denmark. Sam@ is a typically rural district and had 4,885 inhabitants on April 1, 1974. The material of the Aarhus investigation comprised a random sample of children born between January l and December 31, 1968, and residing in the municipality of Aarhus on November 1, 1973. The municipal school administration has a card index of all children of the municipality born in 1968, and the investigated sample was drawn randomly from these 3,574 children. The Aarhus sample consisted of 125 probands. The material of the Sam@ investigation was obtained from the Institute of Psychiatric Demography of the Aarhus Psychiatric Hospital and comprises all children born between January 1 and December 31, 1968, and residing on the island on April 1, 1974. This sample consisted of 58 probands, the total material of the investigation thus comprising 183 probands. Children under institutional care outside the investigated areas but with families residing in the areas are not included in the study. Pre-school children are primarily institutionalized due to mental retardation, and as that is the case in .l-.2 % (Bernsen (1976)) omission of this group cannot have influenced the results. Screening methods Three possible sources of information concerning the symptoms of the children were available: the health authorities, the children themselves, and their parents. Relying solely on hospital admission data has serious limitations from an epidemiological point of view due to their selective nature. Using children of preschool age as the main source of information was also considered inappropriate due to theoretical as well as practical drawbacks. Parents’ reports were thus found to be the most valuable source of information, even though several studies (Chess et al. (1966), Robins (1970)) have stressed that they lack sufficient reliability and may introduce bias in the results. The classical Scandinavian studies were based upon clinical, non-standardized interviews. A similar procedure was found less valuable in the present study,
32 in view of the aim to study as comprehensive a picture of the child‘s mental and physical health as possible in order to allow an overall assessment. In the light of the questionnaires of Macfarlane et al. (1962), Jonsson & Kalvesten (1964), Rutter et al. (1970), and Shepherd et al. (1971), a standard form was drawn up. A pilot study of 11 interviews was carried out to clarify the questions. The final form consisted of 128 queries concerning the family and its social background and prenatal and perinatal circumstances, development, previous diseases, current physical health, abilities, behavioural and emotional symptoms of the child in question. Procedure Prior to the interviews an explanatory letter was sent to the 183 families involved, including those who during the period November 1, 1973 to the time of the investigation had moved away from the municipality of Aarhus. In the Aarhus investigation, 119 of the 125 families selected were induced to participate and personally interviewed by the author. Of the remaining six, two had emigrated from the country, and four were unwilling to cooperate, On Samspr, 56 of the 58 families agreed to participate. No information was available about the two families who had emigrated. The six non-cooperating families all expressed pronounced aversion towards any intrusion into their private life, four giving former conflict with authorities or institutions as the underlying reason. The total participants of the investigation comprised thus 95 boys and 80 girls, corresponding to 95.6 % of the original material. Interviews were aIways carried out in the child‘s home in the presence of one or both parents. Despite an effort to involve the fathers, mothers’ reports played an overwhelming role in the completion of the form. In only three cases did fathers’ reports provide the basis for completing the questionnaires. A personal contact was established with the children, and their behaviour and reactions were observed as well as the parent-child relationship. This information was subsequently supplemented in various ways. In the Aarhus investigation, inquiries were made about hospital admissions and attendance at the prophylactic health controls to the general practitioner (G.P.). On Samspr the survey was of a more intensive nature. A Vieland Test was carried out and parents were questioned about their own physical and mental health. Information from other sources was obtained in the following ways: 1. In collaboration with one of the two G.P.’s on the island all the files concerning the families involved were perused. 2. The families’ contact, if any, with the psychiatric clinic on the island was examined. 3. The health visitor, the social worker, and the family consultant on the island provided supplementary information about the social background of the families.
33
Table 1. The interviewed probands distributed according to sex and place of residence Girls
Boys
Total
abs.
%
abs.
%
Aarhus
67
56.3
52
43.7
119
SaIns@
28
50.0
28
50.0
56
Total
95
54.3
80
45.7
175
The greater intensity of the survey on Sam@ made it possible to give a more comprehensive picture of the attitude of the parents and the social and cultural setting. In the present report, however, only data comparable to data from the Aarhus-survey are represented. Collected data were transferred to punchcards sorted according to the child’s identification number. Quantitative analysis was carried out employing the SPSSsystem (Statistical Package for the Social Sciences, Nie et al. (1975)). The reported significant differences refer to results of X2-tests or, where appropriate, Fisher’s exact test. RESULTS Table 1 shows the distribution of the investigated material according to place of residence and sex. The total profile of the child’s behaviour was divided into four categories, based on symptoms concerning 1. biological functions and motor manifestations, 2. social adaptation, 3. structure of the personality, and 4. current abilities.
On the basis of the parents’ reports, a high prevalence of psychosomatic and behavioural symptoms was found. Table 2 presents the prevalence of selected symptoms concerning biological functions and motor manifestations according to sex and place of residence. It varies considerably, with about 20 % reporting pains in the stomach once a week or more, to 2 % reporting encopresis once a week or more. Table 3 shows the prevalence of antisocial behaviour according to sex and place of residence. Table 4 presents the prevalence of selected behaviour characteristics according to sex and place of residence. From the parents’ reports it appeared that more than 20 % of the children were excessively shy and reserved, moody, worried, ambitious, dominating, wanting to attract attention, or showing frequent loss of temper. Between 10 and 20 % of the subjects were said to be 3 ACTA PSYCH 542
34
Table 2. The prevalence of various symptoms concerning biological maturation distributed according to sex and place of residence
Aarhus
samsz
Total
(%I
(%I
(%I
Symptoms
Stomach-ache Headache Speech disorders Enuresis nocturna Encopresis Nail-biting Thumb-sucking Nightmares Tics
Boys
Girls
Boys
22 4 12 12 3 19 7 13 13
17 6 2 10 2 17 10 6 6 n=52
11 7 32 21 4 7 18
n = 67
4
14 n=28
Girls
Boys
Girls
4 4 7 7 4 14 14 4 4 n=28
19 5 18 15 3 16 11 11 14 n=95
12 5
4 9 3 16 11 5 5 n=80
Table 3. The prevalence of antisocial behaviour distributed according to sex and place of residence
Aarhus
samsz
Total
(%I
(%I
(%I
Symptoms Boys Stealing Lying Truancy Interest in fire Firesetting
3 10 1 22 3 n=67
Girls 0 6 2 9 2
n=52
Boys 4 0 4 25 7 n=28
Girls 0 4 0 7 0 n=28
Boys
Girls
3 7 2 23 4 n=95
0 5 1 9 1 n=80
excessively disobedient, submissive, destructive, aggressive, and lacking in concentration. Excessive jealousy, selfishness, day-dreaming, avoiding attention, fear of new situations or things, and difficulties in establishing contacts were found among 5 to 10 % of the children. Table 5 presents various developmental abilities according to sex and place of residence. An analysis of the overall differences between the urban and the rural sample shows only a slight difference in the behaviour characteristics of the two. Stomach-ache was thus the only symptom reported with a significantly greater frequency ( P = 0.005) in the Aarhus than in the Sam@ sample. An analysis of the present findings in terms of sex differences shows that boys had more problems than girls. No symptom was observed with a significantly greater frequency among girls whereas several symptoms were found more frequently among boys. As shown in Table 6, differences between the sexes were significant in respect of excessive ambition, disobedience, aggressiveness, speech disorders, changes of mood, clumsiness, interest in fire together
35 Table 4. The prevalence of various behaviour characteristics distributed according to sex and place of residence ~
Aarhus
Sams#
(%I
(%)
Behaviour
of temper Mood swings Restlessness Aggressiveness Submissiveness Destructiveness Difficulty in establishing contacts Jealousy Fears Disobedience Day-dreaming Selfishness Dependency (fear of separation) LOSS
_
_
_
_
Total
Boys
Girls
Boys
Girls
Boys
Girls
39 34 27 18 18 13
40 15 17 12 13 12
50
25 25 18 11 14
54 14 18 0 14 4
42 32 26 18 16 14
45 15 18 8 14 9
12 6 4 27 7 13
6 12 8 8 4 2
14 11 0 18 0 7
4 11 0 0 7 11
13 7 3 24 5 12
5 11 5 5
12
17 n = 52
11 n = 28
14
n = 67
n = 28
12 n=95
16 n=80
5 5
Table 5 . The prevalence of the present developmental abilities distributed according to sex and place of residence Aarhus
Sam@
Total
1%)
(%I
(%)
Ability Boys Unable to dress by himself Unable to handle knife (or fork or spoon) Not counting up to 10 Not knowing any letters
Girls
Boys
Girls
7
4
25
4
30(1) 3 12 n=67
29(0) 4 6 n=52
89(0) 14 25 n=28
71(0) 0 7 n=28
Boys
12 47(1) 6 16 n=95
Girls
4 44(0) 3 6 n=80
Table 6. The prevalence of various behavioural items showing significant sex differences distributed according to sex Behaviour Excessive ambition Mood swings Disobedience Interest in fire Clumsiness Speech disorders Aggressiveness
3'
Boys
Girls
(%I
(%I
47 32 24 23 19 18 18 n = 95
24 15 5 9 6 4 8 n = 80
Total
37 x2 = 10.44 P < 0.005 24 xa = 6.54 P < 0.025 15 x2 = 12.28 P < O.OOO5 17 x' = 6.52 P < 0.025 13 x'= 6.13 P < 0.025 11 x' = 8.58 P < 0.005 13 x2 = 4.11 P < 0.05 n = 175
36 Table 7. The retation between symptom load and the investigator‘s as well as the parents’ assessment of the child Symptom load
0-3 Investigator’s assessment* No behaviour problems Behaviour problems Parents’ assessment** No behaviour probIems Behaviour problems
129
2 4
24
4 18
122 31
13 9
* x2 = 46.12, P < 0.001. ** f = 4.65, P < 0.05.
Symptom load
Fig. 1. The material distributed according to “symptom load” and sex (n = 175).
37
with current developmental abilities. There were also marked, but not significant, differences in respect of restlessness, stealing, destructiveness, truancy, selfishness, attraction of attention, tics, nightmares, enuresis nocturna, difficulties with others, and stomach-ache. It is well known (Kunner (1960), Lapouse & Monk (1964)) that the early childhood years are characterized by a variety of emotional and behavioural disorders. These disorders do not constitute disease entities deviating qualitatively from normality as unambiguous criteria for normal behaviour in pre-school childrsn are lacking. Consequently, there is considerable doubt as to the psychopathological significance of such behaviour. In the present study, though each type of behaviour was analysed separately, the need to develop a method for measuring the overall deviance was not overlooked. A statistical delimitation, though it is easy to handle and avoids conceptual problems, has the disadvantage of equating normality with frequent presence, while ignoring the aetiology and prognosis of the various symptoms. Despite methodological disadvantages, it was decided to use the statistical approach in assessing the extent of psychic disorders. Accordingly, any type of behaviour which occurred among 10 % or fewer children was defined as deviant. A score for the total deviance, the “symptom load”, was constructed as follows: The different items were all given the same weight and the child received one point for each deviation. Thirty-seven behaviour characteristics of the standard scheme were reported in 10 % or fewer of the children and consequently the “symptom load” could range from 0 to 37. From Fig. 1, it appears that 101 probands (58 %) had a symptom load of less than 2, symptom loads ranging from 2 to 4 were seen in 58 probands (33 %), and the remaining 16 probands (9 %) presented a deviation of 5 points or more. Besides describing behavioural characteristics, an attempt was also made to elucidate the underlying patterns of association. To investigate clustering of the symptoms, a factor analysis was carried out, based on correlation matrices of the 37 variables constituting the symptom load. The “eigenvalues”, i.e. the fraction of the total variance explained by each factor, were calculated. As a result, 15 factors appeared explaining 67 % of the total variance. On the basis of these data, underlying syndromes or clustering of symptoms could not be determined. The number of maladjusted children was assessed by two methods. Parents were asked to state whether their children were disturbed at the time of the investigation or had been so formerly. It was found that 12 % of the children exhibited behavioural or emotional symptoms at the time of the investigation whereas 11 % had done so previously. Alternatively, the interviewer gave a clinical evaluation of the mental health of the children and found 8 % of the children to have psychiatric disorders and a further 15 % to have minor behavioural or emotional problems. Subsequently, the interrelation between the three different assessments was analysed. It was found (Table 7) that the presence of a symptom load of 4
38 Table 8. The relation between the investigator’s and the parents‘ assessment of the child
Parents’ assessment
Investigator’s assessment behaviour
Behaviour problems
110
25
23
17
No
problems
No behaviour problems
Behaviour problems
y = 9.73,P < 0.01. points or more was significantly related to the parents’ assessment (P < 0.05) as well as the investigator’s assessment (P< 0.01) of the child as disturbed. In addition, the interrelation between the parents’ and the investigator’s assessment was also found to be significant (P < 0.01) (Table 8). On the basis of the three different judgements it was possible to assess the current state of the mental health of the children. Thirty-five probands (20 %) showed good adjustment without behavioural or psychosomatic troubIes. A total of 113 probands (65 %) did well with only minor symptoms. Of these, 74 were found to be undisturbed through these three assessments. The remaining 39 probands, though disturbed in at least one assessment, still showed fair adjustment. Twenty-seven probands, corresponding to 15 %, were poorly adjusted. This group consisted of two subgroups, one comprising the 19 probands found disturbed by the investigator and through one of the other assessments, and the other comprised the eight probands assessed as disturbed through all three methods. The relation between the children’s symptoms and various demographic variables was examined. Social background was assessed by classifying the fathers’ occupations according to the Svalastoga Scale (Svalastoga & Wolf (1969)) and by estimating the annual income of the family. The social setting assessed in these ways was not clearly associated with the child’s adjustment. A variable “social risk” was constructed comprising the following items: born out of wedlock, grown up in a broken home, prolonged stay away from home, death of the parents, not having been brought up by the biological parents, low age of the father, poor economical conditions, unsatisfactory housing. A significant relation (P < 0.05) was observed between a low social risk and a well-adjusted child according to the investigator’s assessment. Housing conditions were examined in terms of sanitation, sleeping facilities, number of rooms, and a garden. These conditions were not found to be related to the child’s deviance. Size of the family seemed of minor importance for the child’s mental health.
39 On the other hand, while older children had higher symptom loads, the youngest children exhibited this condition to a lesser degree than expected. An analysis of the family conditions showed that children from broken homes as well as children not brought up by their biological parents had a significantly higher symptom load. By analogy with “social risk”, a variable “medical risk” was formulated with the following items: pathological pregnancy, very young mothers, birth weight I 2,500 g, complicated delivery, prenatal and perinatal complications. Presence of a high medical risk was related neither to the social background nor to the child’s behaviour problems. About one fourth of the children had been admitted to hospitals on one or more occasions, but the immediate effect of this on the children’s mental health could not be estimated. At the time of the investigation, such admissions seemed to have no relation to the behaviour problems. Severe physical disorders were rarely recorded and apart from a couple of asthmatic cases, no child appeared to have or have had disabling somatic disorders. DISCUSSION The present study was undertaken to assess the extent of psychic disorders among randomly selected children of pre-school age, in order to provide some basis for planning future child psychiatric services in Denmark. As used here, the term “psychic disorder” refers to a condition or behaviour of the child deviant from that expected for his age group, involving suf€ering andlor distress, causing concern to his parents. About 15 % of the children studied were found to have psychic disorders. Unfortunately, about one third of the parents of this group were ignorant and unaware of this fact. In the remainder, though aware of the problem, the parents had not taken the trouble to have their children treated at the local paediatric, child-psychiatric, or child guidance clinics. Underlying reasons for this indifference are many. Some parents were unaware of the local treatment facilities. Some were sceptical as to the desirability of treating psychic disorders, postponing such action until the disorder became a problem. A general feeling that the G.P. should not be troubled with such cases, coupled with a lack of confidence in his professional competence to handle such ailments (an attitude also common in the medical profession), has compounded the problem. COMPARISON WITH OTHER STUDIES Ambiguity concerning the definitions of behaviour disorders of children and the lack of precise frames of reference for the individual symptoms made a comparison of the present findings with those of others difficult. In some studies, even the frequency and intensity of the symptoms encountered are not clearly stated. Danish prevalence studies are also characterized by their diversity of approach. Thus Heinild (1969, 1972) analysed the children treated by a socialpaediatric out-patient clinic, and estimated that only 2 to 4 % of the children
40 in Copenhagen showed errant behaviour. Severe maladjustment and developmental disorders were observed in 5 to 10 % of the 9- to 11-year-old children studied by Vedel-Petersen et a2. (1968), who believed this figure to be an underestimate. According to Helbo (1967, 1972), 26 % of rural children starting school showed reactive symptoms, while one third of all school children studied had psycho-social problems requiring treatment. These are, perhaps, exaggerated evaluations as he classified children with even minor tension phenomena as needing treatment. In contrast, Lunge (1974) reported that about 16 % of 10-year-olds on Samso needed psychiatric help. Even surveys conducted under comparable conditions led to varying conclusions. Behavioural deviances ranging between 13 and 63 %, with 5 to 14 % of the children needing specialist treatment, were recorded by the Swedish 4-year Health Controls (Holst et al. (1970), Goteborgsforsoket (1972), Kiihler (1973)). In this study, a number of symptoms appeared to be more prevalent among boys than among girls. A similar, albeit insignificant, preponderance of psychically disturbed boys was deduced from the analyses of mental health by the three modes of assessment. Predominance of boys among psychically maladjusted children has also been reported by others (Rutter et al. (1970), Chazan & Jackson (1971), Shepherd et al. (1971), Werry & Quay (1971)). Besides a greater number of symptoms, boys frequently manifest traits, causing their parents to seek treatment of them (Wolf7 (1961), Dahl (1970), Hjermind (1971)). Lack of close correlation between social background and psychic problems of children observed in this study is in accordance with the findings of Jonsson & Kalvesten (1964), Lapouse & Monk (1964) and Shepherd et al. (1971). HOWing conditions, too, are seemingly unrelated to the psychic disorders, though further studies, similar to the Stockholm Suburban Project of Tengvald et at. (1974) are warranted to elucidate the influence of modem housing on the psycho-social behaviour of children. IMPLICATIONS FOR FUTURE PSYCHIATRIC SERVICES In this study, no child showed symptoms of a severity demanding immediate admission as an in-patient, but many exhibited less severe disorders. The desirability of treating such cases has been much discussed. According to Lapouse & Monk (1964), deviant behaviour has no pathological significance. A majority of emotional disturbances are said to recede spontaneously (Shepherd et al. (1971)). Contrariwise, others favour treatment of even minor disorders (Jonsson & Kiilvesten (1964), Helbo (1969, 1972)). Prevention is undoubtedly better than cure in terms of suffering, hence, it is unfortunate that disorders considered not severe or serious go undetected and untreated due to the inadequacy of the existing services. Child psychologists and psychiatrists ought to extend their extramural activities and functions as advisors to G.P.’s, health visitors, social workers, and educationists. Even for severe forms of behaviour problems that may recede spontaneously, treatment to shorten their duration is obviously justified and desirable. The duration and clinical significance of these disturbances seem to be correlated not only with
41 their severity but also the setting in which they occur. Of crucial importance is the attitude of parents, who in turn are influenced by social and cultural conditions about which little is known at present. Some disturbed children receive professional assistance; others do not. Why? Equally fragmentary is our knowledge regarding the efficacy of early psychiatric treatment or preventive mental hygiene through a systematic campaign of information. On the other hand, planning and restructuring of future service cannot wait upon such results. Urgent problems require action now. “But the development of services must be planned in such a way that research is built-in to the development in order that planners in the future can know which steps have been effective and which have not. In the absence of research we can only move forward blindly, able to profit neither from our mistakes nor from our successes’’ (Rutter et al. (1970)).
ACKNOWLEDGEMENTS I wish to thank Annelise Dupont, M.D. and the staff of the Institute of Psychiatric Demography, especially Mrs B. Kaldau and Mrs E. Henriksen. I also wish to thank the participating general practitioners, especially T. Bi(rn-Henriksen, M.D., Sam@. REFERENCES Psychiatric illness from birth to maturity: an epidemiological Baldwin, J . A . (1968): study. Acta psychiat. scand. 44, 313-333. Bernsen, A. (1976): Severe mental retardation among children in the county of Aarhus. Acta psychiat. scand. 54, 43-66. Chazan,M., & S. Jackson (1971): Behaviour problems in the infant school. J. Child Psychol. 12, 191-210. Chess, S., A. Thomas & H . Birch (1966): Distortions in developmental reporting made by parents of behaviorally disturbed children. J. Amer. Acad. Child Psychiat. 5, 226-234. Dahl, V. (1970): Et 5 Qrs materiale fra et ridgivningscenter (A 5-year study in a child guidance clinic). Ugeskr. Lzeg. 132, 1169-1175. Goteborgsforsoket med halsokontroll av fyrairingar (Health control of 4-year-olds) (1972): Liikartidningen 69, 1893-1919. Heinild, S. (1969): Social padiatri (Social pediatrics). Ugeskr. Lag. 131, 1901-1911. Heinild, S. (1972): Samspilsramte b@m (Multiproblem families). Minedsskr. prakt. hgegern. 49, 273-302. Helbo, S. (1967): Bfirneproblemer p l landet (Problems of rural children). Ugeskr. h g . 129, 171-174. Helbo, S. (1972): Skolesundhedspleje p l familiebasis (School health work on familial basis). Ugeskr. b g . 134, 1619-1622. Hjermind, E . (1971): De praktiske behandlingsmuligheder for psykisk svaert lidende bfirn (The practical therapeutic possibilities for children with severe mental disturbances). Ugeskr. h g . 133, 1269-1274. Holst, K., E. M . Kohler & L. Kohler (1970): Dalbyundersokningarna: Undersokningar av 4-iringar. (Dalby investigations: Investigations of 4-year-olds). Liikartidningen 67, 3673-3677. Jonsson, G., & A . L. Kiilvesten (1964): 222 Stockholmspojkar (222 boys from Stockholm). Almqvist & Wiksell, Uppsala. Kanner, L. (1960): Do behavioural symptoms always indicate psychopathology? J. Child Psychol. I, 17-25. I
42 Kohler, L. (1973): Health control of four-year-old children. An epidemiological study of child health. Acta paediat. scand., Suppl. 235. Lunge, B. (1974):Personal communication. Lapouse, R., & M . Monk (1964): Behaviour deviations in a representative sample of children. Amer. J. Orthopsychiat. 34, 43-46. Macfarlane, J . W., L . Allan & M . P. Honzik (1962): A developmental study of the behaviour problems of normal children between 21 months and 14 years, 2nd ed. University of California Press, Berkeley, Los Angeles. Nle, N . H., C. H . Hull, I . G . Jenkins, K . Steinbrenner & D . H. Bent (1975): Statistical package for the social sciences. 2nd ed. McGraw-Hill, New York. Robins,L. N . (1970):Follow-up studies investigating childhood disorders. In Hare, E. H., & 1. K . Wing: Psychiatric epidemiology. Oxford University Press, Oxford. Rutter, M., J. Tizard & K . Whitmore (1970): Education, health and behaviour. Longman, London. Shepherd, M.. B. Oppenheim & S. Mitchell (1971): Childhood behaviour and mental health. University of London Press, London. Sundby,P., H . Sommershild & P. C. Kreyberg (1968): Prognosis in child psychiatry. Universitetsforlaget, Oslo and Williams & Wilkins, Baltimore. Svalastoga, K., & P. Wolf (1969): Social rang og mobilitet (Social rank and mobility), 2nd ed. Gyldendal, Copenhagen. Tengvald, K., B. Lagerkvist, S. Lauritzen & P. Olin (1974): Fyrasringar i en ny forort (Four-year-olds in a new suburb). Socialmed. T. 51, 9!?-104. Vedel-Petersen, J., A . From, T . LQve & I . MQrk Petersen (1968): Bflrns opviekstvilkik (The conditions of upbringing). Socialforskningsinstituttets publikationer, No. 34, Copenhagen. Werry, J . S., & H . C . Quay (1971): The prevalence of behaviour symptoms in young elementary school children. h e r . I. Orthopsychiat. 41, 136-143. Wolff,S. (1961): Social and family background of pre-schml children with behaviour disorders attending a child guidance clinic. J. Child Psychol. 2, 260-268.
Received March 23, 1976
Marianne Kastrup, M.D. Institute of Psychiatric Demography 8240 Risskov Denmark
