Abdel-Hady El-Gilany (MBBS, M.Sc, Dr.PH ) and
Mostafa Amr (MBBS, M.Sc, M.D.)*

Family and Community Medicine Department, College of Medicine in Al-Hassa,
King Faisal University, Saudi Arabia
*Lecturer in Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Correspondence
Abdel-Hady El Gilany
Family and Community Medicine Department
College of Medicine in Al-Hassa
King Faisal University
Saudi Arabia.
Professor of Public Health,
College of Medicine,
Mansoura University,
Mansoura 35516
Egypt
Email: ahgilany@gmail.com, ahgilany@hotmail.co.uk

World Health Organization embraces a definition of health as physical, mental and social well-being. Of these elements, mental well-being historically has been misunderstood and often forgotten(1). Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community. The World Health Organization definition of health implies that mental health cannot be achieved merely by preventing and treating disorders. It must address the broader issues affecting the mental well-being of all sectors of the society(2,3). Mental health is a basic human right. The historic Human Right Conventions, passed by the United Nations in 1989, is the first universal and binding international policy statement on the rights of the child. However, many children continue to experience overt or covert denial of access to essential needs such as food, shelter, health care, education, recreation and social support(4). Mental, physical and social functioning are closely associated and interdependent(5).

Current events have highlighted an interest in child and adolescent mental health. Unfortunately, too often this is due to concerns about the mental health consequences of war, prolonged conflict, natural disaster, AIDS, and substance abuse. Special populations of repatriated child solders and street children are a vivid reminder of the many children who have been deprived of an environment that could support healthy development. Further, there is an increased understanding that children who are not mentally healthy can have an adverse impact on the stability and economic viability of nations. Of particular importance is the fact that positive mental health plays a role in supporting compliance and adherence to a broad spectrum of health regimens(6).

Mounting evidence suggests that antecedents of adult mental disorders can be detected in children and adolescents(3). However, for long, the attention dedicated to children and adolescents' mental health has not been commensurate with that dedicated to adults and elderly(7).

In many Middle East countries, like other developing countries, childhood disorders that have priority in health planning are life threatening conditions, such as diarrheal diseases, acute respiratory infections and other childhood infectious diseases. The region has made substantial progress in improving infant and child physical health; however, the mental problems are neglected despite their increase. Child mental health is a relatively new discipline in the Middle East region. With high prevalence rate of trauma and violence in the region's countries, child and adolescent mental health remains a major concern. Children and adolescent mental health in some countries, such as Palestine, Iraq, Somalia and Sudan (Darfur) are a matter of grave concern(7).

The under five population of the Arab world represents about 19.7% of the total population while children and adolescents constitute about 45% of the Middle East population(8,9). Adolescence is a period of change when intellectual abilities are stimulated while cognitive and affective faculties are nurtured. Children and adolescents are influenced by parents, teachers, peer groups, health care providers, the media and the religious and cultural norms in their communities. The health behaviors of adolescents, such as eating habits, use of tobacco and other substances, are crucial to the health and disease patterns that will be observed when this population reaches adulthood(9).

Magnitude of the problem
Worldwide the bulk of evidence suggests that one child or adolescent out of eight suffers from mental health problems at any given point in time. The prevalence of mental problems in children and adolescents in the general community is approximately 20% in the United States, of which at least half suffer from impairment in functioning. The few studies that examined prevalence in the developing world found similar rates(10-13). Only 4 to 6% of these children and adolescents are in need of a clinical intervention for observed significant mental disorders(7,13,14). Major studies regarding psychiatric morbidity in the Arab countries of the Middle East region are scant and no systematic region-wide study has been done. Judging from recent work in Bahrain, Egypt, Morocco, Saudi Arabia and Tunisia, the prevalence of major psychiatric disorders among children and adolescents of this region is similar to other parts of the world(9).

Although children may suffer from a wide range of mental problems there is a poor awareness amongst health care providers about the occurrence of these conditions. The magnitude of mental health problems in children has not yet been recognized sufficiently by many governments and decision makers. They include not only well defined mental disorders, but also the mental health problems of children exploited for labor and sex, and children orphaned, or forced to migrate for economic and political reasons(15).

Early childhood psychiatric problems are child abuse, behavioral problems, in addition to lack of awareness of parents of psychological development of children. The major problems for middle childhood and adolescent period is the greater concern of parents and teachers to focus on academic competition in schools with lack of awareness on individual variation of children and to push them to get the highest score in their academic education without consideration to individual differences. The common mental health problems faced at this age group are anxiety, dissociative disorders, depression, school drop out and acute psychosis(16). Children may suffer from a wide range of other psychiatric illness such as conduct disorders, eating disorders, attention deficit hyperactivity disorders, adjustment disorders, substance abuse and dependence. Suicide rates rise rapidly in adolescence(17).

Findings from Middle East studies

Emotional disorders
Anxiety symptom was reported by 59% of a national survey of Egyptian children and adolescents through a specialized questionnaire(18). More than 35% of school children showed moderate anxiety scores(19). Using a clinical interview, anxiety was diagnosed in 7.9% of school children aged 6-12 years in Egypt(20). More than 10% of primary and preparatory school students in Alexandria, Egypt demonstrated depressive scores(21). A much higher prevalence of psychiatric disorders was reported among children and early adolescence in Iraq (37.4%)(22) and the Gaza strip up to 72.8%(23-25). In Taif, Saudi Arabia 8.4%, 13.5% and 11.6% of male school children and adolescents suffer from depression, anxiety and schizophrenia, respectively(26).

Behavioural disorders
Behavioural disorders present 8.2% of diagnoses in all children attending the outpatient psychiatric facilities in an Egyptian University Hospital(27). Up to 23.5% of preschool children have behavioral problems(28,29). More than 13% of primary school children in the United Arab Emirates have some form of behavioral disorders(30). Behavioural problems in childhood are frequently interpreted as misbehavior that can be managed by punishment or reward within the family. Within the overcrowded schools, teachers are less likely to differentiate between children with developmental disorders, adjustment disorders or mild learning disability(31).

Learning difficulties
Since education is increasing in both urban and rural areas, there is a tendency to see more cases of educational problems. Scholastic underachievement was found among 42.8% in pupils of elementary Egyptian schools(32). The awareness of parents and school staff of children's needs at different phases of development is often inadequate. A child who is an underachiever at school is usually labeled as mentally retarded by the teacher(19). Parents are often over-demanding in relation to the academic achievement of their children, even in the earliest years and this leads to an increase in the school drop-out rate(31).

Child abuse and neglect
There is a dearth of knowledge about the problem of child maltreatment in Arab societies(33). Egyptian studies revealed that violent behavior was higher among children and adolescents subjected to corporal punishment. Hyperactivity and attention-deficit symptoms are encountered more often among students who are underachievers and most often are exposed to corporal punishment(32). Also, female genital mutilation has been studied and found to be prevalent in Egypt, Sudan, Somalia and Yemen. A higher percentage of Arab adolescents in Israel are psychologically and physically maltreated annually. This is associated with feelings of helplessness; psychological adjustment problems and low self-esteem(34). Children who experience maltreatment are three to four times as likely to become depressed or suicidal in adolescence or adulthood. A Moroccan study found that 9.2% of women reported sexual abuse during their childhood which is associated with depressive symptoms(35).

Eating disorders
Eating disorders (e.g. anorexia nervosa and bulimia nervosa) are psychological disorders characterized by severe disturbance in eating behavior. The available literature indicates that anorexia nervosa is rare in Arab countries. Thinness has been regarded as socially undesirable, whereas plumpness is regarded as a symbol of fertility and womanhood(36). However, an Omani study revealed that 33% and 9% of Omani and non-Omani teenagers showed a propensity for anorexic-like behavior, respectively and 12.3% and 18.4% showed propensity for binge eating or bulimia, respectively(37). In Qatar 10.1% of adolescent boys were extreme eaters(38). In the United Arab Emirates (UAE), 23.4% of adolescent girls showed abnormal eating attitudes(39). In Saudi Arabia, the figure is 24.6% among secondary school girls(40).

Handicapped children
A dark and neglected area is the mental health needs and services provided to children and adolescents with special needs. They face three major obstacles. Firstly, some families are ashamed to acknowledge that their child is impaired or delayed. Many children with autism or retardation are kept at home without receiving specialized services. Secondly, when families decide to seek placement for their children in either day centers or residential facilities, they may be faced with fees that they cannot afford given their poor financial conditions. Lastly, even after placing a child in a center, integrating the child later into society can be problematic. Not many schools accept children with a physical or mental handicap. Similarly, (and except for governmental agencies), few business allow those groups of youth to train for jobs when such jobs are well within their capacity. Disabled children frequently end up being kept at the fringe of society, where they continue to be non-productive and develop additional behavioural problems because of the lack of structure in their life(41). Bakr et al(42) and Amr et al(43,44) studied psychiatric disorders in children with chronic renal failure on dialysis and found a prevalence of 52.6% with adjustment disorders the most common. These children have low verbal, performance and full scale intelligent quotient, more depression and internalizing scores as well as more anxiety, somatic complaints, family problems and attention deficit. In UAE, psychiatric disorders were more frequent among children with bronchial asthma (16%)(45) and mental retardation(46).

Nocturnal enuresis was present in 1.9% of school children in Egypt(47) and a higher rate of 8.8% was reported among Jordanian children(48).

Determinants of child and adolescent mental health
The specific etiologies of behavioural and psychological disorders are unknown and probably multiply determined. It is not known exactly how and when the currently healthy children eventually develop specific mental problems making it difficult to plan interventions to prevent future specific dysfunction(49). Mental disorders have many determinants. Biological, psychological, social and societal risk and protective factors and their interactions have been identified across the lifespan from as early as fetal life. Many of these factors are malleable and therefore potential targets for prevention and promotion measures(5).

Risk factors
Risk factors are associated with increased probability of onset, greater severity and longer duration of major health problems(5).

- There are apparent universal risk factors including parental separation and divorce, psychological deprivation, and culture-specific factors, such as polygamy which correlated with manifest psychopathology(6). Poverty, in absence of community safety nets, can make the psychosocial distress worse(9). This is usually accompanied by lack of adequate food, shelter, education or health care.

- In some agricultural communities there is an ambivalent view of children as family property to be used for work, a lack of comprehension that children have a mental life and a failure to understand developmental psychology. Children have to obey the order of parents as a discipline system. This system raised lack of communication between children and their parents, particularly among adolescents.

- Lack of awareness about child mental health. Most children with mental problems or learning difficulties are simply ignored or labeled as slow, disobedient or problem children(50).

- Widespread civil strife and violence: wars and internecine strife disrupt social and community life. Mental morbidities usually accompany or outlast the physical morbidity of wars.

- With wide urbanization, work becomes mechanized, and both parents work away from home. They pass on to their children little knowledge and fewer skills which could earn them the children's respect. It is difficult for parents to train their children in social responsibilities, hence, delinquency and behaviour disorders tend to develop(31). Breakdown of extended families deprives mental patients from the traditional source of support.

- Poor quality school, with less qualified, low paid and poorly committed teachers, have taken a great toil on mental health of children.

- Many perinatal factors are associated with mental disorders e.g. congenital anomalies, inborn error of metabolism, preterm, low birth weight, birth asphyxia, etc. Low birth weight and preterm were associated with cognitive and behavioural deficits, failure to thrive, cognitive problems later in life, academic impairment and school problems and increases the risk of behavioural and psychiatric disorders(51-53).

- In Gulf countries children are left to the care of expatriate non-Arabic home servants. The mental health impact of this type of child rearing practice was not studied.

Protective factors
Protective factors refer to conditions that improve people's resistance to risk factors and disorders.

- Individual protective factors include self-esteem, emotional resilience, positive thinking, problem-solving and social skill, stress management skills and feelings of mastery(5).

- Contrary to Western cultures, Arab culture is based on shame rather than guilt. In spite of rapid social change in the region, the majority of people especially in rural areas belong to an extended family hierarchy. It is considered shameful to care for a psychiatric child away from the family surroundings. Parents of children with learning disabilities or hyperkinetic disorders accept primary responsibility for them, rather than having them looked after in an institution(54).

- Arab society is characterized by strong family ties and close extended family relationships and is strongly influenced by Islamic principles. Social relationships have worked as factors of protection and as support networks. Extended family develops a better bond and support to the family members. Grandparents can ensure continuity of cultural and family traditions by passing on these values to children, thus helping them build a better foundation for their moral and social development with lower rates of delinquency(50).

- Psychotherapy is an important element of psychiatric management in the region, with a strong religious (Islamic and Christian) emphasis. Deeply religious faith and belief in destiny can protect people from feelings of hopelessness and the intention to kill oneself.

- In rural conservative societies, conditions are conducive to the development of happy and socially secure children. Such children learn crafts and appropriate conduct smoothly from their everyday coexistence with parents and elders and are gradually initiated into the fuller social responsibilities of the extended family community. Those living in the countryside have a special tolerance of children with mental disorders and learning disabilities and the ability to assimilate them into their community. Those people are rehabilitated daily by cultivating the countryside and learning simple crafts under the supervision of family members(31).

- The practice of prolonged and exclusive breastfeeding in traditional communities improves the cognitive development as measured by intelligent quotient and teacher's academic ratings in children at age of 6.5 years(55).

Situation of child and adolescent mental health in the Middle East

Traditional religious healers (sheikhs) have a major role in primary mental care in the region. They deal with minor neurotic, psychosomatic and transitory psychotic states using religious and group psychotherapies, suggestions and devices such as amulets and incantations(54,56). Until recently, child mental health and psychiatry were not offered high priority in Middle East countries. They are recently addressed in the official health plans of some Middle East countries e.g. Egypt and Tunisia. Large-scale community surveys are scarce in the Arab world. There is a scarcity of valid and culture relevant Arabic psychiatric research instruments(8).

In the Middle East needs in child psychiatry are increasing because the region is very young and because of decreased pressure of traditional health problems especially infectious diseases. Primary health care workers, because of their commitments to physical health needs, are not able to deliver mental health care. They are not confident in managing mental disorders.

In the past 20 years, the countries of the Eastern Mediterranean region have adopted national programs of mental health as a method of meeting the needs of their peoples. This has brought in a new era in the provision of mental health care using the primary health care approach. The ultimate goal is to decrease both the stigma of mental illness and the reliance on large institutions for their treatment through community based care programs. Although the majority of the countries have agreed in principle to integrate mental health into primary health care delivery system, implementation so far has been limited for a variety of reasons(56).

Middle East countries have few psychiatrists specialized in childhood problems. Universities do not offer a degree in child psychiatry in spite of the magnitude and severity of mental health problems in childhood. The problem is not only the lack of resources for providing mental health care to children, but also the attitude of the community to child mental health problems.

Misconceptions about mental disorders are widespread, not only just among the lay public, but also among health professionals. It is commonly believed that mental disorders are not real disorders. They are considered to be rare in developing countries, or are considered to be largely untreatable(57). In fact, most parents and teachers are not sensitive enough to pick up subtle forms of behavioural indications and often ignore or neglect them. It is only when the problem becomes severe and disabling that some attention is paid to the child. In early stages it is much easier and simpler to intervene and push the developmental trajectories into healthier and adaptive courses(17).

Special education schooling for children with learning disabilities and mental retardation is present in Egypt, Jordan, Lebanon, Saudi Arabia, Tunisia and the United Arab Emirates(8).

Future challenges
Child mental health problems are expected to increase in future due to rapidly changing social and cultural values, fragmentation of the family system, and loss of religious values(50). The vast majority of children and adolescents do not receive any mental health services at all. Mental health needs of children and adolescents are complex and huge. The high prevalence of child mental health problems and the fact that a sizeable segment of the population in the Middle East are children, it is pressing to develop systems to identify mental health needs in children and the necessary means to provide preventive and therapeutic services to them.

Most of the existing laws dealing with mental health are now old; having been written prior to the new concept of community psychiatry and the integration of mental health into other health services(58). An attempt to update them is now in progress(31). The main challenge remains to convince the states to allocate funds for more widespread and well organized mental health services, necessary for the prevention and intervention of the ever increasing demands in the child and adolescent population.

The challenges are to include child mental health in primary health care and school health services, train family doctors and pediatricians to deal with the main bulk of mental disorders, and raise public awareness regarding recognition of mental disorders and referral routes. School mental health assessment and screening of school children by qualified psychologists or social workers with referral to psychiatrists is mandatory if we want to provide our children with healthy mental development. What we need is a public awareness that mental disorder can start in childhood and that its early detection and management can spare the community a high percentage of adulthood disorders. Most parents of emotionally disturbed children prefer to take them to a general practitioner or pediatricians rather than a psychiatric clinic.

Special attention should be paid to children with special needs, delinquent juvenile, adolescent with substance abuse, abused and neglected children, children with separated parents, civil wars and political unrest. Feasible and cost-effective service delivery has to be developed to meet the mental health needs of children and adolescents.

Assessing impairment in children and adolescents is a complex task involving the need for cultural specific tools, agreement on criteria for impairments, and the implication of disorders for a reduction in the ability to be productive(3). There is a need for simple culturally sensitive screening tools in local language for different psychiatric illnesses. These tools need to be validated and be appropriate for application in primary health care.

Another challenge in the Middle East countries is the role played by traditional healers. Many of them are strongly against any medication intake and therefore constitute an obstacle rather than an asset to mental health care provision. A policy of integration, to have among its goals an examination of the nature of the traditional practices, and a process of improving the more efficacious and safe components of this form of care. A training package is needed to be prepared for these healers. Any future program should articulate collaborative linkages between traditional and modern medicine systems.

Novel approaches are essential to satisfy needs of rural, remote dispersed populations, refugees, displaced indigenous and disaster stricken populations.

Research in child mental health is not highly developed. Research might seem like a luxury in poor countries, but is essential to work towards the development of a local research capacity. Research should not represent a simple replication of Western studies(6). There is a need to initiate research that will answer questions about the specificity of diagnosis in the Middle East region, the ways in which services can be developed, how treatments are best utilized, role of traditional healer and how the burden of diseases can be measured at the community level.

What can we do?
Continued neglect of the mental health needs of children and adolescents is unacceptable and must stop(3). The problems of mental illness are complex, with implication for health care, economy, and social and cultural practices. The prevention of mental disorders has been neglected, despite the fact that nearly half of these disorders are amenable to primary prevention(59). Mental health needs are often present in systems other than the health or mental health arena. Children with mental health problems are often first seen and first treated in the education, social services, justice or juvenile systems(3).

Ample evidence exists that early intervention programs are a powerful prevention strategy. The most successful programs addressing risk and protective factors early in life are targeted at child populations at risk(60). There is a wide range of preventive measures that have been found to reduce the risk factors, strengthen protective factors, and decrease the onset of some mental disorders and improve positive mental health(5). There is no simple solution. A combination of approaches may be more successful than a single strategy. Empowerment of primary health care staff to tackle mental health problems is mandatory for the success of any intervention program.
Promotion of mental health and prevention of mental disorders needs to be a multipronged effort(5). There is a need for greater integration of the health, education and welfare sectors to provide a more comprehensive policy for prevention of child mental health problems.

Preventive interventions may seek to enhance protective factors, which are positive behaviours or features of environment that lessen the likelihood of negative outcomes or increase the possibility of positive outcomes. In their meta-analysis of 177 primary prevention programs designed to prevent behaviour and social problems in children and adolescents, Durlak and Wells(49) found that most of these programs yield significant effects.

Promotion of maternal and child health programs will contribute significantly to improvement of child mental health.

Changing school ecology will improve emotional and behavioural functioning of students. Teachers are in a very powerful position. Their behaviour as a model and their opinions as to what constitutes good mental health, impact very directly on the concepts of mental health adopted by their pupils. They are concerned in promoting some aspects of mental health, such as improving the self-esteem of their learners, teaching acceptable ways of relating to others and managing stress and adversity(1). For children, school is the second home and no child mental health can be conceived without proper attention to school mental health.

In view of the lack of human resources, mental health policies and legislation should develop partnerships with other sectors e.g. non-governmental organizations, and international organizations to provide mental patients with the best care possible. Training in child mental health care should include all health care personnel including doctors, nurses, social workers and psychologists. The involvement of teachers in this program is vital.