الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
 |  | from | 139 |  |  |
| | | from | 139 | | |
Abstract
Disruptive behavior disorders which comprise ODD and CD; are the commonest mental health disorders of childhood and adolescence. They are considered among the commonest reason for referral to child and adolescent mental health services. DSM-IV-TR defines ODD as a pattern of negativistic, hostile and defiant behavior lasting at least 6 months, while, CD is defined as a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated. CD is classified according to age of onset into two main types; childhood type and adolescent type and according to severity into mild, moderate and severe. ODD/CD arises out of a complex mix of risk and protective factors originating in the biopsychosocial constellation of an individual. ODD, CD and APD are organized hierarchically and developmentally as if they reflect age-dependent expressions of the same underlying disorder. ODD and CD are very frequently diagnosed in the context of various comorbid psychiatric disorders, example; ADHD, MDD, anxiety disorders, alcohol and substance abuse disorders. A high proportion of children and adolescents with ODD/CD grow up to be antisocial adults with impoverished and destructive lifestyles. Multimodal treatment approaches, have demonstrated the greatest efficacy in managing ODD and CD.
The present study was conducted aiming at; estimating the prevalence of DBDs (ODD and CD) among primary school children in Alexandria Governorate and detecting some of its determinants.
To fulfill this aim, the study was conducted on a sample of 1192 primary school children in Alexandria Governorate using multistage stratified random sample. The sample was chosen from the four most crowded educational zones namely; El Montaza, East, El Amreya and Middle. from each educational zone, two public and one private primary school were chosen at random. from each school, 3 classes were chosen at random one class from 2nd grade, another from 3rd grade and the third class was chosen from 4th grade, forming total of 36 classes.
For the execution of this work a structured self administered questionnaire was developed to collect data from parent /caregiver about the child including:
1. General characteristics of study sample including; educational zone, type of school, grade, name, age, sex, family size, number of rooms, father’s education and occupation, mother’s education and occupation and the socio-economic level of the family.
2. Other data included; Parental relationship, marriage status, consanguinity between parents, any psychiatric problems in family, smoking and drug abuse in family. Child’s hobbies, favorite programs on TV, number of friends, academic achievement, complying to school homework, reading and writing difficulties.
3. Developmental difficulties, sensory or motor problems any chronic disease, any psychiatric symptoms as depression, anxiety or phobia, any problematic behavior as lying, stealing or aggression, toilet training problems, punishment for wetting or soiling clothes, child’s relationships, siblings differentiation, family violence, and punishment for misbehavior.
The Revised Ontario child health study scale Parent /caregiver form was used to identify children with ODD and CD. Internal consistency (Cronbach’s alpha) was done for the scale and was considered adequate (0.716 for ODD and 0.605 for CD). Validity was performed using discriminant validity and it was significant (table I).
The results of the present study revealed the following:
The study sample included 1192 children. The 4 chosen educational zones were represented, with 32.1% from El Montaza, 24.8% from East, 22.9% from Middle and 20.1% from Al Amreya. The three selected primary grades (2nd, 3rd and 4th grades) were represented by 30.3%, 38.6% and 31.3% respectively. Girls represented 52.8% while boys constituted 47.2%. The age of children ranged from 6-12 years with a mean age of 8.6 years ±1.07. Concerning socioeconomic status 30.3% were from low and very low class, 32.4% from moderate class and 37.2% were from high socioeconomic class.
The prevalence of ODD among the study sample was 9.2% and the prevalence of CD was 5.1%. Boys outnumbered girls in both ODD (boys11.5%, girls 7.2%) and CD (boys 8.7%, girls 1.9%). Gender as a determinant showed that boys were 1.69 times more at risk to develop ODD and 4.9 times more at risk to develop CD than girls.
The following family determinants were statistically significant for ODD:
- Low and very low socioeconomic status (OR=2.26).
- Fair (OR=2.26) and bad (OR=5.24) interparental relation.
- Father’s illetracy or only read and write (OR =3.34) and primary education (2.49), mother primary education (OR=2.26).
- History of family violence (OR= 5.73), family psychiatric problems (OR=4.58) and sibling differentiation (OR=5.16).
Whereas family determinants for CD were;
- Low and very low socioeconomic status (OR=4.07).
- Divorce (OR=3.37), fair interparental relation (OR=4.39).
- Father’s illitracy or only read and write (OR=6.98), primary (OR=3.39) and preparatory education (OR=3.86), mother’s illetracy or read and write (OR=8.32), preparatory and secondary education (OR =3.02, 2.25 respectively).
- History of family violence (OR=12.39), family psychiatric problems (OR= 4.75) and sibling differentiation (OR=10.18).
Statistically significant child determinants for ODD were;
- Watching violent programs (or= 2.50) and non-violent cartoons (or=0.57).
- Staying at home at school time (or=2.51), going out with friends at school time (or=6.60), weak, fair , good and very good scholastic achievements in respect to excellent (or=3.60, 3.49, 1.87 respectively), not complying (or=2.86) and sometimes complying to home work (or=3.07), reading and writing diffficulties (or=2.63,2.93 respectively).
- Psychiatric symptoms (OR=3.07), aggression (OR=5.96), stealing (OR= 10.08), lying (OR=4.63), stuttering (OR=3.36).
- Problems in diffication training (OR=2.71), enuresis (OR=2.62), reaction to soiling or wetting clothes (reasurance, shouting or calling names, beating OR=0.39, 2.44, 1.73 respectively).
- Bad and good mother-child relationship (OR=19.21, 3.15 respectively), bad and good father-child relationship (OR=6.01, 2.42 ), bad and good teacher-child relationship (OR=14.59, 2.98), bad and good peer-child relationship (OR=7.92, 3.24).
Regarding CD, child determinants were:
- Watching violent programs (OR=4.69), violent cartoons (OR= 2.47) and watching non-violent cartoons (OR=0.28).
- Staying at home at school time (OR=3.89), going out with friends at school time (OR=8.34), weak, fair, good and very good scholastic achievements in referance to excellent (OR=13.47, 10.55, 2.96 respectively), not complying (OR=5.71) and sometimes complying to home work (OR=5.38), reading and writing diffficulties (OR=3.69, 4.42 respectively).
- Delayed walking (OR=4.31), mobility problems (OR=39.61), chronic disease (OR=2.86), psychiatric symptoms (OR=3.33), aggression (OR=9.83), stealing (OR= 19.45), lying (OR=13.95), stuttering (OR=5.35).
- Problems in urination training (OR=3.99), problems in diffication training (OR=3.39), enuresis (OR=3.93), reaction to soiling or wetting clothes (reasurance,shoutingor calling names, beating OR=0.45, 2.37, 1.88 respectively).
- Bad and good mother-child relationship (OR=20.55, 5.73 respectively), bad and good father-child relationship (OR=11.43, 4.27 ), bad and good teacher-child relationship (OR=30.09, 6.65), bad and good peer-child relationship (OR=21.11, 4.86).
As for determinants related to punishment inflected on chiildren having ODD and CD, more than appropriate punishment, shouting or calling names as punishment and beating were statisticaly significant (OR=4.49, 2.52 and 2.68 respectively for ODD and OR=8.80, 3.73, 6.19 for CD).
According to stepwise multistage logistic regression analysis, the possible variables proved to be significant predictors of ODD were: Aggression (OR=3.25), reassurance and help after wetting or soiling clothes (OR=0.51) (protective), bad and good child relation with mother in reference to very good relation with mother (OR=9.27, 1.69 respectively). In addition to child relation to teachers in reference to very good relation, bad and only good relations proved to increase risk of ODD (OR= 4.03, 1.76 respectively). While, the variable proved to be significant predictors of CD according to stepwise multistage logistic regression were: Aggression (OR=5.02), stealing (OR=65.56), lying (OR=5.56), problems with urination training (OR=3.88), having good relationship with father in reference to very good relation (OR=3.27), shouting or calling names (OR=3.18) and history of family violence (OR= 3.42).
Based on the results of present study, the following was recommended:
• Universal health education programs about normal development of children behavior and disruptive behavior disorders; risk factors, early manifestations, consequences, when and where to seek help.
• Health education programs to help children develop self-regulation, anger management, social skills and social problem-solving skills as these can serve as important protective factors against disruptive behavior disorders.
• Conducting parenting programs that help parents learn strategies that are more effective in dealing with undesirable behaviors to reduce negative and harsh parenting, and emphasize the dangers of harsh verbal and physical discipline. Also parenting programs should clearly illustrate that child rejection or sibling differentiation leads to a lot of mental health problems.
• Health education about association between bad relation between parents, parental divorce and family violence and children disruptive behavior disorder and its consequences on child. This can be conducted in schools.
• Emphasizing the importance of treating family psychiatric problems including depression and substance abuse before these problems affect family relations and lead to parenting problems.
• Simple questionnaires should be designed and used for detecting children disruptive behavior disorder which can be easily administered and interpreted by family physicians, school physician and pediatricians.
• Parents should observe their children closely and know their friends well to avoid their association with deviant peers.
• Parents should encourage their children to have hobbies and play sports on regular basis.
• Government should provide safe places for children and adolescents to play sports and nurture talents and skills and help with studying under supervision of responsible adults.
• Parents should monitor what television programs their children are watching and educate them not to watch violent programs.
• Educational programs targeting parents of children with chronic physical or psychiatric illness or disability about how to alleviate stigma from their children and help them merge with their peers.
• Household organization system should be adopted by all parents. Household organization is an ongoing, instrumental process by which family life becomes structured and predictable through agreed-upon standards and routines. A household that is functionally well organized may operate as a protective factor by facilitating the transmission of parental values by correct parenting methods.
• Health education programs should be established concerning the nature, early manifestations and consequences of DBDs. These programs should be directed to the social worker, school teachers and health personnel, through different health and educational facilities.
• Early screening of primary school children for CD/ODD should be integrated within the health appraisal services of school program. Children identified to be at high risk should be referred to a psychiatrist for further clinical diagnosis and evaluation.
• Special training courses should be available for normal child development in social, psychological and physical aspects and how to detect abnormal development directed to school physicians, teachers, and social workers.
• Parents and teachers should work together in helping children. Teachers should inform parents about any behavioral changes in their children and also should inform their association with deviant friends. Parents should trust teacher’s judgment as they observe the children on daily bases and can notice any changes in behavior.
• Teachers should be educated about importance of bonding with children. Bonding with teachers represents emotional closeness between students and their teachers. It has been related to lower levels of problem behavior; such closeness may promote children’s internalization of adult norms for behavior and also provide them with emotional support to resist the negative influence of deviant friends.
• Teachers should avoid differentiation between children or calling them names as this may lead to their rejection from their peers and increase risk of disruptive behavior.
• Harsh discipline and physical punishment should be incriminated by law in schools as they mostly do harm than good.