Prevalence of Mental Disorders in Caregivers of Children and Adolescents under Outpatient Psychiatric Follow-Up
- 1. Faculdade de Medicina de Ribeirão Preto (FMRP), Brazil
Abstract
Background: Children exposure to inadequate parental practices or low involvement with caregivers constitute risk factors for child development, increasing vulnerability to threatening events that are external to the family environment.
Objective:The main objective of this study was to identify the prevalence of mental disorders in the population of caregivers of children attending the child psychiatry outpatient clinic at the São Jose do Rio Preto Medical School (FAMERP)-SP.
Method: A cross-sectional study in which 50 caregivers were randomly selected from the population who had attended the outpatient clinic in the last three years. They were interviewed after signing an informed consent form, following approval of the research project by the ethics committee of the university. The tutors were met and underwent short, structured interviews using the MINI instrument, which contributes to the detection of mental disorders in clinical practice. The primary outcome assessed was mental disorders and the secondary outcome was sociodemographic data.
Results: The results pointed to a significant prevalence of mental disorders among these caregivers. There was a statistically significant association between sociodemographic factors and some mental disorders: Intellectual disability in children associated with age and level of education of caregivers 73.7% (elementary school), 38.7% (secondary and higher education); Attention Deficit Hyperactivity Disorder in children and marital status of caregivers 52.9% (single, widowed/divorced) and 24.2 (married).
Conclusion: We conclude that mental disorders in caregivers may be related to the presence of mental disorders in children and adolescents.
KEYWORDS
- Child psychiatry
- Epidemiology
- Family relationships
- Parent-Child Relations
- Caregivers
CITATION
Samara JR. Jr, Konno YT, Filho ABM, de Araujo Filho GM, Ruiz GSM, et al. (2024) Prevalence of Mental Disorders in Caregivers of Children and Adolescents under Outpatient Psychiatric Follow-Up. Ann Psychiatry Ment Health 12(2): 1196.
INTRODUCTION
Child and adolescent psychiatry is a modern specialty. The first chapter focusing on children and adolescents was written by Maudsley [1]. The main objectives are the diagnosis of psychiatric illnesses, which may compromise child development, and their treatment. There is abundant evidence that mental disorders in childhood result from a combination of genetic factors, biological predisposition and environmental factors [2]. Environmental factors, which include family dynamics, greatly impact children’s development and mental health, since this is the social context of the most striking and early childhood experiences [3].
The child’s exposure to inadequate parental practices (conflicts, violence, coercion) or low involvement with caregivers constitute risk factors for child development, increasing vulnerability to threatening events that are external to the family environment, such as delinquent practices and involvement with drugs [3].
The FAMERP Child and Adolescent Psychiatry outpatient clinic has existed for over 20 years. It is one of the outpatient clinics that constitute the Psychiatry residency service at the aforementioned Medical School, serving an average of 570 children annually. Children are referred from different municipalities due to the most varied complaints.
The objective of this outpatient clinic is to formulate diagnostic hypothesis(es) of the cases, as well as to develop a therapeutic plan: medical and other professional management in related areas, such as Psychologists, Speech Therapists, Occupational Therapists and others, thus constituting a multidisciplinary treatment, in which professionals from different areas work in an integrated manner.
This research aims to measure, through tracking, the prevalence of mental disorders in a specific population – formed by caregivers (parents, grandparents, uncles and aunts) of children who undergo follow-ups at the Child Psychiatry outpatient clinic of Medical School of São José do Rio Preto (FAMERP)., identifying the characteristics and prevalence of psychiatric disorders (PD) of caregivers of children who are under psychiatric medical follow-up in a teaching hospital, in addition to evaluating sociodemographic data of the researched population and correlating them to the different PD.
METHODS
Study design
Cross-sectional study with quantitative methodology carried out on a sample of guardians (parents/grandparents/uncles and aunts) of children and adolescents diagnosed or with a diagnostic hypothesis of a mental disorder, who began follow-up at the Child Psychiatry outpatient clinic between 2016 and 2019.
Participants
The inclusion criteria were: Guardians between 18 and 70 years old, restricted to parents, grandparents, uncles or aunts; Guardians of children who began follow-up during the study period. Only one of them was interviewed (parent, grandparent, uncle or aunt).
The exclusion criteria were: Guardians who are not parents, grandparents, uncles or aunts; Tutors who were unable to understand the instruments used to collect data; Guardians of children who began follow-up outside the study period.
Procedures
FAMERP’s child psychiatry outpatient clinic allocated fifty guardians for children who started follow-up during the period of 2016 through 2019. The choice was random. Subsequently, the Mini International Neuropsychiatric interview scale was applied, a short and structured diagnostic interview, with an administration time of approximately 15 minutes; version 5.0, used in this study, mapping the DSM-IV criteria onto them. MINI is a structured interview scale, in order to detect the presence of mental disorders as the primary outcome. (4). We replaced the diagnosis of “Mental Retardation” to “Intellectual disability”, as we find it more appropriate to modern times, as it is used in DSM-
5. Sociodemographic data were collected as secondary outcomes: gender, education, marital status, family income, religion and previous psychiatric treatment.
The children’s diagnoses were grouped into the following categories: A) Intellectual disability (mild or moderate, with or without behavioral changes; B) Mood Disorder (Mild depressive episode; Unspecified mood disorder); C) Non-ADHD Externalizing Disorder (Oppositional Defiant Disorder – ODD; Conduct Disorder; Unspecified Hyperkinetic Disorder); D) Anxiety Disorders (Non-generalized anxiety disorder; Generalized anxiety; Panic disorder; Obsessive compulsive disorder).
The caregivers’ psychiatric diagnoses were studied and for analysis purposes, some were grouped into categories. The following diagnoses were considered as “other mood disorders”: recurrent depressive episode; major depressive episode with melancholic features; hypomanic episode; dysthymic disorder; mood disorder with psychotic features and manic episode. In “anxiety disorders” the following were considered: generalized anxiety disorder; agoraphobia without current panic disorder; panic disorder (lifelong); social phobia; obsessive-compulsive disorder; current panic disorder and symptom-poor attacks. In “psychotic syndrome” the following were considered: current psychotic syndrome and psychotic syndrome (lifelong).
Statistical analysis
Descriptive statistics and exploratory data analysis were performed, which included mean, median, standard deviation and variation for continuous variables and number and proportion for categorical variables. The normal distribution of continuous variables was verified using asymmetry, kurtosis and the Kolmogorov-Smirnov test. Statistical analysis was performed using IBM-SPSS Statistics version 24 software (IBM Corporation, NY, USA).
Ethical aspects
The study was approved by the FAMERP ethics and research committee under the number 1,165,581.
Funding
This study was financed by the authors’ own funds, without third-party funding.
RESULTS
Descriptive analysis
In total, 50 caregivers were included in the study, with an average age of 37.6 years and the majority (94%), were female. The demographic characteristics and history of previous psychiatric treatment of the caregivers are displayed in Table 1.
Table 1: Demographic and clinical data of the 50 guardians included in the research
Variables |
N=50 |
Guardian age, years |
37,6 ± 7,5 |
Gender, n (%) |
|
Female |
47 (94) |
Male |
3 (6,0) |
Education, n (%) |
|
Incomplete elementary |
18 (36) |
Complete elementary |
8 (16) |
Incomplete high school |
19 (38) |
Complete high school |
4 (8,0) |
University education |
1 (2,0) |
Marital Status, n (%) |
|
Married |
19 (38) |
Stable union |
14 (28) |
Single |
9 (18) |
Divorced |
7 (14) |
Widower |
1 (2,0) |
Family Income |
|
Up to I minimum wage |
20 (40) |
From 1 to 3 minimum wages |
23 (46) |
More than 3 minimum wages |
7 (14) |
Religion, n (%) |
|
Catholoc |
31 (62) |
Evangelical |
16 (32) |
Atheist |
3 (6) |
Previous psychiatric treatment, n (%) |
|
NO |
33 (66) |
YES |
17 (34) |
Note: Numerical variables are described as mean ± standard deviation; categorical data described in number (percentage).
Amongst the psychiatric diagnoses of caregivers, we found the following prevalence: Other Mood Disorders in 21 caregivers (21;42%), Anxiety Disorders (20;40%), Depressive episode (20;40%), Psychotic syndromes (4; 8%), Post Traumatic Stress Disorder (2.4%), and Bulimia Nervosa (2.4%). The risk of suicide was also measured using item y of the MINI; Among these caregivers: 35 caregivers had no risk (70%), low risk in 11 (22%), moderate risk in 1, (2%), and high risk in 3(6%).
As for the children, 38 (76%) were male and the average age was 10.6 years (standard deviation 2.6 years). The main diagnoses were Intellectual Disability (19;38%), Hyperactivity and attention disorders (17; 34%), and anxiety disorders (10;20%). Autism Spectrum Disorder (9.18%), Externalizing Disorders other than ADHD (9.18%), Mood Disorder (6.12%), Behavioral Disorders due to the use of psychoactive substances (1.2%), Eating Disorders (1.2%), Unspecified school skills disorders (1.2%), Combined multiple motor and vocal tics (1.2%), and Unspecified non-organic psychosis (1.2%), were also identified.
Comparative analysis
As for the comparative analysis of the caregivers’ demographic data, such as education, marital status, religion, income and gender with the main disorders identified in this group, such as Other Mood Disorders, Anxiety Disorders and Major Depressive Episode, no statistically significant associations were found.
However, when we performed a comparative analysis between the sociodemographic characteristics of guardians and the most prevalent diagnoses of children and adolescents, we were able to verify statistically significant associations between age and schooling with intellectual disability, and marital status with ADHD. The analysis of the association between guardians’ demographic variables and the diagnosis of Intellectual Disability is shown in Table 2.
Table 2: Analysis of the association between guardians’ demographic variables and the diagnosis of intelectual disability in children
|
Intellectual disability |
|
|
Guardian Characteristics |
Yes (N=19) |
NO (N=31) |
P Value |
Age, years |
41,05 ± 8,26 |
35,55 ± 6,30 |
0,011 |
Education, n (%) |
|
|
|
Elementary school |
14 (73,7) |
12 (38,7) |
0,016 |
High school/university education |
5 (26,3) |
19 (61,3) |
|
Marital status, n (%) |
|
|
|
Single/divorced/widower |
4 (21,1) |
13 (41,9) |
0,130 |
Married/stable union |
15 (78,9) |
18 (58,1) |
|
Family income |
|
|
|
< /=1 minimum wage |
8 (42,1) |
12 (38,7) |
0,812 |
> 1 minimum wage |
11 (57,9) |
19 (61,3) |
|
Religion, n (%) |
|
|
|
YES |
18 (94,7) |
29 (93,5) |
1,000 |
NO |
1 (5,3) |
2 (6,5) |
|
Note: continuous variables are described as mean ± standard deviation; categorical variables are described in number (proportion).
The analysis of the association between guardians’ demographic variables and the diagnosis of ADHD is shown in Table 3.
Table 3: Analysis of the association between guardians’ demographic variables and the diagnosis of Activity and attention disorder in children
|
Activity and attention disorder |
|
|
Guardian Characteristics |
Yes (N=17) |
NO (N=33) |
P Value |
Age, years |
35,88 ± 5,72 |
38,55 ± 8,24 |
0,240 |
Education, n (%) |
|
|
|
Elementary school |
8 (47,1) |
18 (54,5) |
0,616 |
High school/university education |
9 (52,9) |
15 (45,5) |
|
Marital status, n (%) |
|
|
|
Single/divorced/widower |
9 (52,9) |
8 (24,2) |
0,042 |
Married/stable union |
8 (47,1) |
25 (78,8) |
|
Family income |
|
|
|
< /=1 minimum wage |
10 (58,8) |
10 (30,3) |
0,051 |
> 1 minimum wage |
7 (41,2) |
23 (69,7) |
|
Religion, n (%) |
|
|
|
YES |
15 (88,2) |
32 (97,0) |
0,264 |
NO |
2 (11,8) |
1 (3,0) |
|
Note: continuous variables are described as mean ± standard deviation; categorical variables are described in number (proportion).
It was identified that parents with only elementary school education had more children with intellectual disabilities (73.7%), than those with secondary/higher education (38.7%), while parents with secondary/higher education had more children with no intellectual disability (61.3%), than those with only primary education (26.3%).
Age was another factor that showed a statistically significant relation between the sociodemographic data of tutors and the diagnosis of Intellectual Disability, being more prevalent among those with 35.55 ± 6.30 than among those with 41.05 ± 8.26.
When it comes to the comparative analysis between demographic factors of guardians and children with ADHD, there was a significant association between marital status and the presence of this disorder. In this case, single-parent families had more children with this diagnosis
DISCUSSION
In the present study, there was a predominance of young tutors, predominantly female, married and with low family income. Low education reflects a clear characteristic of the population under study, as they come from regional cities, small populations and a large amount of work linked to rural areas. These factors are directly related to the reported low income.
In this study, the following diagnoses predominated: Intellectual Disability, ADHD, Anxiety disorders and Autism Spectrum Disorders. This prevalence is in disagreement with the literature, since Anxiety disorders and ADHD are more prevalent than the aforementioned neurodevelopmental disorders (ASD and Intellectual Disability). Regarding the diagnosis of caregivers, the following prevailed: Mood Disorders, Anxiety Disorder, Major Depressive Disorders. Comorbidities were checked. In this case, the frequency showed greater agreement with the literature [5].
We know that childhood and adolescence represent phases of life that are also susceptible to the occurrence of psychiatric disorders, the formation of which will occur through the interaction and through imbalance between innate factors, such as genetic and neurobiological, and those belonging to the socio- environmental environment, which highlights the dynamics and risk factors directly linked to the family.
Regarding family factors, we could highlight stressful conditions, lack of cohesion, illness of caregivers and maternal mental health. All of these, acting in isolation or in an integrated manner, can be contributory to childhood illness [6].
As for the comparative analysis of the caregivers’ demographic data with the main disorders identified in this group, no statistically significant associations were found. We do know, however, that socio-economic factors, directly linked to the aforementioned socio-demographic characteristics, can contribute to the formation of mental disorders [7].
The association between schooling and intellectual disability can be understood if considered that intellectual stimulation or the lack of it can be a factor in a better or worse prognosis for intellectual disabilities [8]. We also highlight the higher prevalence in rural areas, where caregivers with lower levels of education reside [9]. Age was another factor that showed a statistically significant relation between the sociodemographic data of tutors and the diagnosis of Intellectual Disability, but in this case, there is a contradiction with the literature, in which older age is a risk factor [10].
When it comes to the comparative analysis between demographic factors of guardians and children with ADHD, single-parent families had more children with this diagnosis. Studies show that there is a greater degree of dissatisfaction and marital discord among the parents of these children. It is also known that greater instability can corroborate the expression of the problem, even if it is not the only cause [11,12].
The study has certain limitations, considering that it was a cross-sectional study. We therefore believe that there is a need for further studies in order to strengthen the hypothesis of an association between environmental factors, especially family illness, and mental disorders in childhood and adolescence.
In conclusion, a statistically significant association was observed, which has already been demonstrated in other studies, especially with regard to sociodemographic factors. In this study, specifically, it was identified a correlation between socio-demographic data such as age and schooling with Child Intellectual Disability and also the marital status of caregivers in relation to children with ADHD. In view of the above, we stress the need to improve services that deal with children’s mental health, since this study and others demonstrate the importance of expanding interventions, often including the concomitant treatment of children and their caregivers.
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