الفهرس 
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Abstract
W
e conclude that there was a delay in seeking psychiatric help and that externalizing behavioral problems were the main reason for seeking help, awareness programs are needed to increase the public knowledge about symptoms of internalizing problems and to decrease the length of the duration of illness before reaching mental health facilities.
Other healthcare services and traditional healers played an important role in the pathway of care for children.
Awareness programs that target Primary health care practitioners, pediatricians, and schoolteachers are urgently needed to shorten the duration of illness among children. A way must be found for appropriate collaboration between psychiatrists and traditional healers in helping children with psychiatric disorders.
Several factors including residence, parents’ educational level, gender, socioeconomic class played an important role in the pathways of care for children and so may be an important target for modifications and improvements in this sense.
STRENGTHS AND LIMITATIONS
Strengths:
- The study adds to the currently available data on help seeking pathway of children in Egypt. Thus, it could be of help in raising awareness among the public, schoolteachers, and other health care professionals about early symptoms of mental illness which can eventually shorten the delay in seeking help at psychiatric facilities.
- The study was conducted at two clinical setting (governmental mental health facility and university hospital in Cairo, Egypt), which results in a better generalization of the results.
- The use of a comprehensive assessment tool that includes the use of the gold standard semi-structured clinical interview (K-SADS: PL) for the clinical diagnosis of psychiatric illnesses along with other possible comorbidities.
Limitations:
- Our study did not explore the effect of delay and seeking help at other non-psychiatric services on the children.
- Families were self-reporting previous data which were not officially recorded, this subjects the study to recall bias.
RECOMMENDATIONS
1. Research Recommendations:
- The findings of the current study need to be replicated in longitudinal studies with larger sample size and extending for a longer period with follow up to know the impact of delayed psychiatric consultation.
2. Clinical implications and recommendations:
- Raising awareness about child mental health is urgently needed among pediatricians, different health care professions (i.e PCPs and neurologists) and schoolteachers. This can markedly shorten the length of the duration of mental illness before reaching mental health facilities with early referral.
3. Public and media recommendations:
- Designing and implementing awareness programs that aims to lessen the stigma of mental illness and to also increase awareness about symptoms of internalizing problems in our society should be launched. This can be through media with involvement of social media and school campaigns. These programs should intend to explain the nature of mental illness, and simply demonstrate treatment options with layman phrases that can be easily understood by the public so that it can reach as much population as possible.
- Campaigns to assess the efficacy of awareness programs are needed.
SUMMARY
P
sychiatric disorders in children and adolescents are unquestionably ubiquitous and burdensome (Akhter et al., 2017). Data indicate that the need for child and adolescent mental health services are not fully met anywhere in the world. The scenario is comparatively worse in developing countries (WHO, 2005).
Untreated pediatric mental illness leads to complications including lifelong disability, substance abuse, and suicidal behavior (Wang et al., 2005). Health care providers and many of the population in Egypt are not as aware of this as they should be, Children and adolescents are particularly vulnerable as they do not participate in the decision-making process but can only seek care through the pathways that the parents may choose (Hussein et al., 2012). Delay in reaching psychiatric service can possibly lead to the deterioration in the overall quality of life and can worsen the desirable outcome.
In this study we aimed to investigate different routes that parents take before reaching the child psychiatric services. And to further discover reasons for any delay in seeking psychiatric help. In addition, we aimed to estimate the duration of mental illness before reaching psychiatric services.
from January 2020 to March 2021, a total of 350 cases were recruited in our comparative cross-sectional study that took place at the child outpatient clinic at Al Abbasia mental health hospital and Okasha institute of psychiatry, Ain Shams university hospitals in Cairo. both diagnosed and newly diagnosed cases of both genders aged below 12 yrs. old. Cases were subgrouped into group I (Okasha institute) with 181 children and group II (Al Abbasia hospital) with 169 cases.
Cases that refused to participate or withdrew during the interview were excluded.
Ethical Considerations:
Approval of the study was obtained from the ethical committee of the faculty of medicine Ain Shams University and from the ethical committee of Al Abbasia psychiatric hospital and an informed consent was offered for legal guardians of children participating in the study with full description of the aim of the study and the role of each participant. The participants were informed that this study could be used for scientific publication without the disclosure of the participants’ personal identity. The children’s guardians were informed that their decision to participate in the study or not will not affect the access to treatment.
The tools used in the study are the following:
1. An author designed checklist including questions about personal and sociodemographic data, different consultations and referral places sought before reaching psychiatric help, most distressing symptom, reasons that contributed to any delay before reaching proper service.
2. The updated and re-validated version of Fahmy and Sherbini’s socioeconomic scale was used to assess the socioeconomic class of the studied sample (Fahmi and El-Sherbini, 1986; El-Gilani et al., 2012).
3. The Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, Arabic version: a semi structured clinical interview scale, Present and Lifetime version. The K-SADS-PL was used to diagnose or to confirm diagnosis of the recruited cases. (K-SADS-PL) (Kaufman et al., 1996; Moussa et al., 2011).
4. The Child Behavior Checklist for ages 4-18 (CBCL 4-18), Arabic version was completed by one of the parents to assess severity of internalizing and externalizing problems (Achenbach, 1991; El-Sheikh et al., 2003).
5. The of Stanford–Binet Intelligence Scale fifth edition, Arabic version was used to diagnose intellectual disability (Farag, 2011).
Results showed that the average delay in reaching psychiatric services was 27.33 ± 19.63 months. The majority of parents, 39.7%, 1st consulted psychiatrists as regards to their child’s symptoms. Meanwhile, the most commonly reported source of referral was relatives in 26.9%.
The most frequently mentioned reason for taking an action, or in other words the most distressing symptom that caused the parents to reach for help at a psychiatric setting, was behavioral problems (46.3%).
The most commonly reported reason for delay was lack of awareness that the child’s behavior could be a sign of a disorder, this reason was mentioned by 79.7% of the sample. Parents were reluctant because they did not know where to go or from who to get help for their child symptoms.
Eighteen percentage of the parents sought traditional healers help for their children’s condition. The majority of the parents stated that they preferred to seek traditional healers’ advice due to their easy access.
By performing regression analysis including all study variables to assess the strength of associations and remove confounding effects, the only factors that remained significant with traditional help seeking were age> 10.5, female gender, father education, residence, poor academic achievement.
The above findings indicates that awareness programs are needed to increase the public knowledge about symptoms of internalizing problems and to decrease the delay in reaching psychiatric services enhancing the child’s quality of life later on through receiving proper diagnosis and treatment as early as possible.
Schoolteachers and other health care professionals such as pediatricians and primary care physicians should be targeted by child mental health training programs to help detect early mental illness symptoms thus sparing families time and referring to psychiatric services directly thus helping the child, the families, and making good use of the available psychiatric services by using them properly.
from the strengths of the current study, The study was conducted at two clinical setting (governmental mental health facility and university hospital in Cairo, Egypt), which might allow better generalization and comparison. Our study was limited by applying cross-sectional design, it did not explore the effect of delay and seeking help at other non-psychiatric services on the children. Also, Families were self-reporting previous data which were not officially recorded, this subjects the study to recall bias.
Future directions for research include the need for the findings in the current study to be replicated in longitudinal studies with larger sample size and extending for a longer period with follow up to know the impact of delayed psychiatric consultation on children. Clinically, raising awareness about child mental health is urgently needed among pediatricians, different health care professions and schoolteachers. This can markedly shorten the length of the duration of mental illness before reaching mental health facilities with early referral.
Finally, we recommend Designing and implementing awareness programs that aims to lessen the stigma of mental illness and to also increase awareness about symptoms of internalizing problems in our society to be launched. This can be done through media with involvement of social media and school campaigns.