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1 ORIGINAL PAPER Psychiatric Disorders Among New Child and Adolescent Attendees in an Outpatient Setting of a Sungai Petani Hospital: A Registry from January 2014 to December 2014 Nazariah Harun, Ravivarma Rao Panirselvam, Yusni Yusuff Department of Psychiatry & Mental Health, Hospital Sultan Abdul Halim, Sungai Petani, Kedah, Malaysia Abstract Introduction: Children and adolescents requiring mental health services are increasing. This paper is a registry of new clients in the Child and Adolescent Mental Health (CAMH) outpatient clinic of Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah, Malaysia from January 2014 to December Objectives: We aimed to determine the trends of different types of mental disorders in first contact clients at an outpatient CAMH clinic in HSAH. Thereafter, we sought to compare the differences in demographics with types of illness and treatments modalities. Method: We reviewed electronic case records retrospectively for the study period from January 2014 to December 2014 and universal sampling was done. Results: During the study period, there were 160 new cases. The highest number of patients were from the primary school age group with a mean age of 9.98 years. The highest incidence was Attention Deficit Hyperactivity Disorder (23.8%), followed by Autism Spectrum Disorder (17.5%) and others at 15.6%. Out of those sampled, 61% were treated pharmacologically and 39% were receiving non-pharmacological treatment. Conclusions: There is a need to enhance and expand services to enable the client and family to obtain the necessary intervention. With improved screening and empowerment of the family, better outcomes could be achieved for the client. Keywords: Child, Adolescent, Mental Health, Service Utilisation, Malaysia Introduction A powerful statement was made by WHO in 1948: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The accepted principle is that there is "no health without mental health however often mental health is neglected in individuals and even more in children and adolescents. Parents or adults tend to neglect the mental health of children as they tend to be more focused on physical health and do not think children are capable of emotions. There is a myriad of developmental difficulties seen in children such as mixed specific developmental disorders, atypical specific developmental disorders, reading

2 disorder, arithmetical disorder and articulation disorder according to the age of the child. Psychological, behavioural and even physical symptoms can manifest resulting from conflict within the child or with their parents or caregivers (Woon,T.H 1981). The need for psychiatric and mental health services in Malaysia is high as evidenced by the National Health and Morbidity Surveys done in 1996, 2006 and 2011 which have shown a consistently high and rising trend of psychiatric morbidity among adults as well as children and adolescents. In Malaysia, the National Health and Morbidity Survey (2011) found the psychiatric morbidity in children (5-15 years old) to be approximately 20% summing to about 1 million individuals. These groups of children have mental health issues such as developmental disability, emotional and behavioural disorders (NHMS, 2011). The prevalence of mental health problems among children and adolescents aged 5 through 15 years showed an increasing trend from 13.0% (95% Confidence Interval [CI]: ) in 1996 to 19.4% (95% CI: ) in 2006 and 20.0% (95% CI: ) in In 2011, male children and adolescents and those who were in less affluent families were significantly associated with mental health problems. The findings indicate that even though mental health problems among children and adolescents in Malaysia is increasing, the rate of increase has decreased in the past five years. Socially and economically disadvantaged groups were most vulnerable to mental health problems (Noor Ani et al. 2015). In Malaysia, child and adolescent psychiatry services began at University Malaya Medical Centre in 1968 where-in they collaborated with multidisciplinary teams (Paediatrics, Clinical Psychologists and Medical Social Workers). Child and adolescent psychiatry services soon extended to other government facilities and currently there is a Child and Adolescent Psychiatry Unit in all regional psychiatry centres. The inception of Child & Adolescent Psychiatry Mental Health Unit (CAMH) services in Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah, Malaysia was in The service is run by 1 Child and Adolescent Psychiatrist assisted by 2 medical officers and 1 general psychiatrist at any one time. The clinic is also supported by allied health staff consisting of staff nurses and clinic attendants. This paper is a registry of psychiatric disorders among new child and adolescent clients in the CAMH outpatient clinic of Hospital Sultan Abdul Halim (HSAH), Sungai Petani from January 2014 to December Objectives We aimed to: 1. Determine the trends of different types of mental disorders in first contact clients at an outpatient CAMH clinic in Hospital Sultan Abdul Halim. 2. Compare the differences in demographics with types of illness and treatments modalities. The rationale of conducting this study was that the above mentioned data was not available in the Northern Peninsula region of Malaysia and disease epidemiology might differ from other parts of the country and world.

3 Methods Retrospective review of electronic case records and universal sampling was done. The sample group were all new cases seen in the outpatient clinic of the Child and Adolescent Mental Health (CAMH) Unit of Hospital Sultan Abdul Halim, Sungai Petani from January 2014 to December The initial assessments were conducted by clinicians and diagnosis was according to the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5). The assessment comprises of a psychiatric interview and mental status examination. Data analysis was done using IBS Statistics Version 22. Results A total of 160 patients were sampled. Ages of patients ranged from 2 to 17 with a mean age of Predominant clients were boys with (61.9%, n = 99) versus girls (38.1%, n = 61). Malay clients were the most (68.8%, n = 110), followed by Indian (16.3%, n = 26) and Chinese (14.4%, n = 23) clients. Highest incidence was attention deficit hyperactive disorder [ADHD] (23.8%, n = 38), followed by intellectual disability (21.3%, n = 34) and autism spectrum disorder (17.5%, n = 28). The details of incidence of psychiatric conditions among sampled population is shown in Table 1. Table 1. Frequency of Psychiatric Illnesses in Sampled Population at CAMH Clinic, HSAH Illness Frequency Percentage (%) Abuse ADHD Anxiety-Spectrum Autism Spectrum Disorder Bipolar disorder Deliberate Self Harm Depression Enuresis Intellectual disability Intellectual disability with Abuse Others Schizophrenia-Like The frequencies between age groups were as the following: preschoolers & toddlers (29.4%, n = 47), primary school (33.1%, n = 53) and secondary school (37.5%, n = 60). Age groups were identified as Malaysian schooling age as per Ministry of Education

4 Malaysia guidelines being less than seven for preschoolers & toddlers, seven to twelve years of age for primary school and thirteen to seventeen for secondary school. The highest incidence of illness among preschoolers and toddlers is autism spectrum disorder (44.7%, n = 21) followed by ADHD (29.8%, n = 14), primary school group is ADHD (39.6%, n = 21) followed by intellectual disability (32.1%, n = 17) and secondary school group is collectively other disorders (28.3%, n = 17) and intellectual disability (20.0%, n = 12). Diagnosis stratified by age groups is illustrated in Figure 1. Figure 1. Age Groups by Diagnosis When compared with gender, the three most common illnesses were mostly prevalent in boys as opposed to girls: ADHD (84.2%, n = 32 vs. 15.8%, n = 6), intellectual disability (50%, n = 17 vs. 50%, n = 17) and autism spectrum disorder (85.7%, n = 24 vs. 14.3%, n = 4). Incidence of psychiatric illness when compared with ethnicity, ADHD and intellectual disability were prevalent in

5 Malay (25.5%, n = 28; 19.1%, n = 21) and Chinese (30.4%, n = 7; 26.1% n = 6) clients while intellectual disability and deliberate self-harm were prevalent in Indian clients (26.9%, n = 7; 23.1%, n = 6). Regarding defaulter rate, predominantly most illnesses have good follow-up rates with exception of abuse (100%, n = 5), enuresis (100%, n = 2), deliberate self-harm (60%, n =3) and intellectual disability with abuse (50%, n = 1). Percentage of defaulters was noted to be higher in the non-pharmacological group, 48% versus the pharmacological group, 29% as shown in Table 2. Table 2. Defaulter rate in Non-pharmacological vs. Pharmacological Groups Frequency Percentage Non-pharmacological Defaulter 47 48% Non-defaulter 51 52% Pharmacological Defaulter 18 29% Non-defaulter 44 77% When this was tested for statistically significant association using the Chi-square test as shown in Table 3. Table 3. Chi Square Test for Association between Therapy Modality and Defaulter Rate Defaulter Non-defaulter Marginal Row Totals Nonpharmacological 47 (39.81) [1.3] 51 (58.19) [0.89] 98 Pharmacological 18 (25.19) [2.05] 44 (36.81) [1.4] 62 Marginal Column Totals (Grand Total) The Chi-square statistic is The P value is This result is significant at p < Discussion The gender and ethnicity data obtained from the study correspond to population demographics of Sungai Petani. The highest number of our clients came from the school going group as most likely teachers or parents/caregivers noted that they were

6 struggling in academia and have difficult behaviour. Learning difficulties, behavioural issues and poor academic performance is common reasons for referral of children to mental health services. However, there is a lack of systematic developmental screening in early childhood in Malaysia and accessibility to mental health services and intervention is currently limited. Hence, based on quantitative estimates from a study suggested a total of 1.4 million children with mental health difficulties that interfere with normal functioning and development are deprived from receiving adequate services for intervention (Peters, 2010). Furthermore, with the advent of LINUS (Literacy and Numeracy Screening) programme in Malaysian schools since 2012, more cases would be detected earlier as compared to before with the catchment group primarily targeted at primary school goers. It is also not surprising that those with ADHD and Intellectual Disability have the highest incidence and this is reflected by another study done locally (Norhaniza et al. 2010). This also corresponds to Western literature on epidemiology of such illnesses. In a study by Boyle et al (2011), data showed that developmental disabilities (DDs) are common: about 1 in 6 children in the U.S. had a DD in This data also showed that prevalence of parentreported DDs has increased by 17.1% from 1997 to This study underscores the increasing need for health, education and social services, and more specialised health services for people with DDs. The study also showed the prevalence of any DD in was 13.87%. Out of that, prevalence of learning disabilities was 7.66%; attention deficit hyperactivity disorder (ADHD) was 6.69%; other developmental delay was 3.65%; and autism was 0.47%. Furthermore, data reflected males had twice the prevalence of any DD than females and more specifically had higher prevalence of ADHD, autism, learning disabilities, stuttering/stammering and other DDs. Interestingly, those on medication are significantly more adherent. This is most likely because caregivers could see improvement in their children while on medication. Those on pharmacological treatment were mainly diagnosed with ADHD. The Multimodal Treatment Study of Children with ADHD (MTA) showed that for both parent and teacher ratings of primary ADHD symptoms (i.e. inattention and hyperactivity/impulsivity), medication management alone was clearly superior to behavioral treatment alone. The MTA study demonstrated that carefully monitored treatment medication in follow up is more effective than intensive behavioural alone up to 14 months (MTA group, 1999). There could also exist a bias on part of parents who believe pharmacological management is superior compared to behavioral treatment leading to better adherence. On all the other outcome measures reported, medication management and behavioral treatment did not differ significantly. Limitations One setback we faced is the novelty of our study demographics leading to inability to compare descriptive data. Many studies involving child and adolescent psychiatry are specific e.g. eating disorders, depression or self-harm vs. a bird s eye view of the entire service. Comparative data would provide strength to associations and enable further hypothesis especially regarding health seeking behaviour of caregivers which forms a crux of CAMH management. Another bias that needs to be appreciated with our data is the presentation of single diagnosis and not dual diagnosis which occurs in this age group. When sampling

7 was done and participants with dual diagnosis were captured, the more debilitating of illness was coded. This was a matter of condensation of data for analysis. Conclusions As with most descriptive studies, more questions are unearthed with the data obtained. More data on child and adolescent psychiatry services is required for an accurate reflection of epidemiology and service requirements. One such modality would be registering visiting CAMH clinics by Child and Adolescent Psychiatrists which provide a bulk of workload to the primary CAMH team. Screening programmes like LINUS show evidence in bridging the gap of the clinical iceberg to therapy. However there is also a need to enhance and expand services to enable the client and family to obtain the necessary intervention timely. With improved screening and empowerment of the family, better outcomes could be achieved for the client. No conflicts of interests declared. References 1. Woon, T.H. Child and Adolescent Psychiatry in Peninsular Malaysia. Med. J. Malaysia. Vol 36.No 3.September Psychiatry Morbidity. A report of the 4th National Health and Morbidity Survey Institute of Public Health, Ministry of Health Malaysia. 3. Ahmad, Noor Ani et al. Trends and Factors Associated with Mental Health Problems among Children and Adolescents in Malaysia. International Journal of Culture and Mental Health 8.2 (2015): PMC. Web. 7 May Peters Huberta. Mental health: Special needs and education. Asean Journal of Psychiatry Jun;(1): Coleen A. Boyle, Sheree Boulet, Laura A. Schieve, Robin A. Cohen, Stephen J. Blumberg, Marshalyn Yeargin-Allsopp, Susanna Visser, Michael D. Kogan. Trends in the Prevalence of Developmental Disabilities in US Children, Pediatrics.May A 14 month randomized clinical trial of treatment strategies for Attention Deficit Hyperactive Disorder. The MTA Cooperative Group Multimodal Treatment Study of children with ADHD. Gen Psychiatrt Dec; 56(12): Corresponding Author Dr. Nazariah Aiza Harun Add: Department of Psychiatry & Mental Health, Hospital Selayang, Selangor Darul Ehsan Malaysia aizaharun@gmail.com