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Reporting Questionnaire for Children as a Screening Instrument for Child Mental Health Problems in Iraqi Kurdistan

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Reporting Questionnaire for Children as a Screening Instrument for Child Mental Health Problems in Iraqi Kurdistan
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  http://tps.sagepub.com Transcultural Psychiatry DOI: 10.1177/1363461507074949 2007; 44; 5 TRANSCULT PSYCHIATRY  Qahar, Jihan Rasheed and Anne-Liis von Knorring Abdulbaghi Ahmad, Anas M. Abdul-Majeed, Aras A. Siddiq, Fatima Jabar, Jabar   Mental Health Problems in Iraqi KurdistanReporting Questionnaire for Children as a Screening Instrument for Child http://tps.sagepub.com/cgi/content/abstract/44/1/5   The online version of this article can be found at:   Published by: http://www.sagepublications.com   can be found at: Transcultural Psychiatry Additional services and information for http://tps.sagepub.com/cgi/alerts Email Alerts:   http://tps.sagepub.com/subscriptions Subscriptions:   http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://tps.sagepub.com/cgi/content/refs/44/1/5SAGE Journals Online and HighWire Press platforms): (this article cites 7 articles hosted on the Citations    © 2007 McGill University. All rights reserved. Not for commercial use or unauthorized distribution.  at AKADEMISKA SJUKHUSET on August 17, 2007 http://tps.sagepub.comDownloaded from   Reporting Questionnaire for Children as aScreening Instrument for Child Mental HealthProblems in Iraqi Kurdistan A BDULBAGHI A HMAD ,A NAS M.A BDUL -M AJEED ,A RAS A.S IDDIQ ,F ATIMA J ABAR ,J ABAR Q AHAR ,& J IHAN R ASHEED Dohuk University  A NNE -L IISVON K NORRING Uppsala University  Abstract To identify child mental health problems in a mid-sized to largecity in Iraqi Kurdistan,the Reporting Questionnaire for Children (RQC),followed by the Child Behaviour Checklist (CBCL) and the Post-traumaticStress Symptom Checklist for Children (PTSS-C),were administered ininterview form to the caregivers of806 school-aged children.To coverdifferent categories ofchildren,four samples were randomly selected fromamong the general population ( n =201),orphans ( n =241),primary medical care patients ( n =199),and hospital patients ( n =165).The RQCrevealed satisfactory validity against a deviant CBCL cut-off.The screeningcapacity ofthe RQC was further supported by its similarity to the CBCL indistribution ofproblem scores among the four samples and its positivecorrelation with the CBCL,but not with the trauma-related PTSS-C.Although the general population showed lower problem scores than theorphans and the two clinical samples,problem scores in all instrumentswere considerably higher than those reported from other societies.TheRQC seems to be useful as a first-stage screening instrument for childmental health problems in Kurdistan. Vol 44(1):5–26 DOI:10.1177/1363461507074949www.sagepublications.comCopyright © 2007 McGill University  transculturalpsychiatry A RTICLE March2007 5    © 2007 McGill University. All rights reserved. Not for commercial use or unauthorized distribution.  at AKADEMISKA SJUKHUSET on August 17, 2007 http://tps.sagepub.comDownloaded from   Key words behaviour problems • CBCL • Kurdistan children • PTSS-C •RQC The first study on child mental health problems in Iraqi Kurdistan wasconducted using a trauma-related instrument to identify post-traumaticstress disorder (PTSD) and other stress reactions in children following the‘mass-escape tragedy’(MET) in March 1991 and again two years later(Ahmad,1992;Ahmad,Mohamed,& Ameen,1998).In April 1991,theUnited Nations (UN) established a safe haven in the northern part ofIraqiKurdistan,allowing most ofthe families to return to their home regions.Since then,the UN has provided the population with food and essentialhealth services.Although the reconstruction ofvillages was supported by nongovernmental organizations,most ofthe population remained in citiesat the time ofthe study.An exception was the survivors ofthe genocideoperation ‘Anfal’, 1 who were placed in temporary camps in the region.In1993,a study ofa sample ofchild survivors of‘Anfal’found that 78% hadPTSD (Ahmad,Sofi,Sundelin-Wahlsten,& von Knorring,2000).One ofthe most widely used tools for conducting exploratory studiesin child mental health is the Child Behaviour Checklist (CBCL;Roussos,Karantanos,& Richardson,1999).The CBCL covers a broad spectrum of psychopathology and is an economic way ofassessing children’s adaptivebehaviour and psychopathology.Norms and cut-offscores for pathology on the CBCL have been determined in different child populations in bothdeveloped and developing countries (Achenbach,Howell,Quay,&Conners,1991;Crijnen,Achenbach,& Verhulst,1997;Larsson & Frisk,1999).In a recent study,parent-reported problems for children andadolescents were analysed on CBCL data from general population samplesin Australia,Belgium,China,Germany,Greece,Israel,Jamaica,the Nether-lands,Puerto Rico,Sweden,Thailand,and the United States ofAmerica(Crijnen et al.,1997).Medium effect sizes for cross-cultural variationswere found in total problem,externalizing and internalizing scores.Theomnicultural means for total,externalizing and internalizing problemsfrom the study differed among the 19 cultures.Puerto Rican scores werethe highest,and Swedish scores the lowest.Age and gender variations werefound to be consistent across cultures.The first published study using CBCL data from Kurdistan was a follow-up study oforphans during 1992–1993 (Ahmad & Mohamad,1996).Thesrcinal English version ofthe CBCL was administered in interview formto the caregivers oftwo groups oforphans,one group living in orphan-ages and the other in traditional foster care.At one-year follow-up,themeans for CBCL total problem score had increased among the children inorphanages,and decreased among the children in foster care.Boys in the Transcultural Psychiatry 44(1)6    © 2007 McGill University. All rights reserved. Not for commercial use or unauthorized distribution.  at AKADEMISKA SJUKHUSET on August 17, 2007 http://tps.sagepub.comDownloaded from   orphanage group had more symptoms than girls on both test occasions,whereas boys and girls in the foster care group had almost similar meansfor problem scores on both test occasions.The means for total problemscores in the foster care sample were higher in younger than in olderchildren,whereas older children in the orphanage sample had higherproblem scores than younger children.Another study ofKurdistanianrefugee children in Sweden revealed higher scores than a comparativeSwedish group,both regarding caregivers’and children’s own reports(Sundelin-Wahlsten,Ahmad,& von Knorring,2002).In order to address child mental health needs,experts in seven develop-ing countries,under the sponsorship ofthe World Health Organization(WHO),carried out collaborative operational research and developedinternationally reliable screening techniques (WHO,1977).These tech-niques usually employ a two-stage process.During the first stage,screen-ing allows caregivers to report the presence or absence ofclearly definedsymptoms in children.This first-stage screening is designed to identify ‘potential cases’that may then be followed up using more time-consumingstandardized psychiatric assessments.One such screening instrument is theReporting Questionnaire for Children (RQC;Tadesse,Kebede,Tegegne,&Alem,1999a).The RQC is a 10-item questionnaire administered in inter-view form to the caregivers ofchildren.It has been shown to identify moderate to severe mental retardation,significant degrees ofemotional orbehavioural disorder,which adversely affect schooling or socialization,andpsychotic disorders among children (Tadesse,Kebede,Tegegne,& Alem,1999b).A single positive item was considered an appropriate cut-offforscreening cases and perhaps for pointing towards a particular disorder(Giel,Harding,& Ten Horn,1988).Receiver Operating Characteristic curve(ROC) analysis was used to examine the validity ofthe RQC amongEthiopian children and revealed 88% sensitivity in identifying casesdiagnosed by a psychiatrist using a diagnostic interview according to theDSM-IV (Tadesse et al.,1999b).The specificity ofthe screening instrumentin this sample was 65%.The positive discriminating power for individualitems was found to be highest for ‘wetting/soiling’and ‘being lonely,’andlowest for ‘stealing’and ‘abnormal speech.’Sensitivity of100 and 90% wasfound in the Philippines and Sudan,respectively and a specificity of70 and63% in the Philippines and Colombia,respectively (Giel,de Arrange,&Clement,1981;Giel et al.,1988).Using a cut-offpoint ofat least one positive RQC item as a screeningtechnique,the frequencies ofchildren having a potential mental disorderin Malaysia,India and the Philippines were 26–44% (Kasmini,Kyaw,Krisknawami,Ramli,& Hassan,1993).In Sudan and Colombia the preva-lence rates for behavioural problems among children attending a primary healthcare service were found to be 12 and 29%,respectively (Giel et al., Ahmad et al.:Child Mental Health Problems in Iraqi Kurdistan 7    © 2007 McGill University. All rights reserved. Not for commercial use or unauthorized distribution.  at AKADEMISKA SJUKHUSET on August 17, 2007 http://tps.sagepub.comDownloaded from   1981).In Ethiopia,a survey utilizing the RQC revealed that 21% ofboysand 25% ofgirls aged 3–12 years suffered from mental illness (based on asingle item),whereas a community-based survey ofchildhood behaviouraldisorder in the same country showed a prevalence of18% when the sameinstrument was used (Mulatu,1995;Tadesse et al.,1999a).The differenceswere attributed to age,the use ofdifferent methodologies,the differentproportions ofurban children in the two studies,or socioculturaldifferences between the communities studied.The present study was part ofepidemiological research to estimatemental health problems in different child populations (a general popu-lation,orphans,outpatients at a primary care centre and hospital in-patients) in a mid-size to large city in Iraqi Kurdistan.In order to identify as many ofthe children’s mental health problems as possible,the screen-ing instrument (RQC) was followed by a more exploratory instrument(CBCL),and the trauma-related questionnaire,Post-traumatic StressSymptoms for Children (PTSS-C).The aim ofthis article is to assess thevalidity ofthe RQC as a first-stage screening instrument to identify childmental health problems among children in Kurdistan. Method Subjects This study was initiated in June 1999 in Dohuk in the western region of Iraqi Kurdistan,a city with a population ofabout 230,000,ofwhich 60%were children.The vast majority ofthe population srcinally came fromthe surrounding rural areas.They had been exposed to the deportationprogrammes ofthe Iraqi government in the late 1970s,the military operation ‘Anfal’in 1988 and the MET in March 1991.Families began toreturn when the city was included in a safe haven under UN protection inJune 1991.During the study period,the population subsisted mainly onthe UN’s World Food Program (WFP),making the standard oflivingessentially comparable for all subjects.Four random samples ofschool-aged children were recruited from thegeneral population,orphan care system,a primary medical care centre andthe only hospital in the city,which was a university hospital.In total,871children (461 girls and 410 boys) aged between 6 and 18 years were high-lighted from available lists ofthe target groups.The general population sample comprised 206 children who wererandomly selected from the computerized register ofthe WFP,the only organization with a register ofthe population ofDohuk when the study started.The orphan sample comprised 245 children,recruited from socialcare authorities in the city.An orphan in this study was defined as any  Transcultural Psychiatry 44(1)8    © 2007 McGill University. All rights reserved. Not for commercial use or unauthorized distribution.  at AKADEMISKA SJUKHUSET on August 17, 2007 http://tps.sagepub.comDownloaded from 
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