Help Seeking Process among Children Attending Psychiatry Clinic in Tirana, Albania.

OBJECTIVE: The goal of this study was to investigate all the potential routes to Child/Adolescent Psychiatry Clinic-University Hospital Center (CAPC-UHC) in Tirana. The article provides demographic data, as well as further information on the types and amounts of services children/adolescents received during the process of seeking help related to different diagnoses.
METHOD: The study was conducted in CAPC-UHC in Tirana, during September 2006-September 2007. Data were collected from 162 children and their parents using Strengths and Difficulties Questionnaire (SDQ) and Pathways Encounter Form. The sample consisted of 53.1% (86) males and 46.9% (76) females. The mean age was 9.5+4.4 years.
RESULTS: Out of the total number of cases that sought care to CAPC; 55, 6% were referred by parents themselves, while the rest were referred by others. There was a significant effect of gender to intervals from the onset of problem to the first career (F=10.803, p=0.001), as well as a significant effect of gender to total time intervals from the onset till the specialist of child mental health problem (F=6.742, p=0.01).
CONCLUSIONS: This is the first study investigating the help seeking process to psychiatric care in CAPC Tirana-Albania and may serve as a good start in generating evidence based on child/adolescent mental health service. Further multicentre studies will enhance the values of the findings, since the present study was performed in a single service, and in a setting lacking previous works with similar scope that could have served as references.

Childhood psychiatric disorders are common and may often be associated with heavy use of health services. Up to one third of children and adolescents attending primary care and pediatric department have clinically significant psychopathology (1).

Epidemiological data is essential for the placement and development of a public policy as well as various programs to improve mental health in children and adolescents.

Goldberg and Huxley's (1992) Pathways to Care Model conceptualized the selection processes involved in the presentation, recognition, and referral of adults with psychiatric disorders. It enables observable levels of service use to be differentiated and has been successfully applied on children (2).In Zwaanswijk and colleagues’ model (3), GP recognition sometimes followed mental health service use (as the GP does not have a gate-keeping role in some countries). Pathways for children are more complex as they rely on adults such as parents and teachers to identify their problems and initiate service use. A vast amount of different pathway studies on children/adolescent mental health problems has been done (4, 5, 6, 7, 8, 9, 10, 11, 12, 13) and reported, but as the organization of and interface between primary and specialist care vary across countries, research findings may be only partially transferable.

As of now, in Albania there exists only one child/adolescent mental health service (CAPC) and serves as both in and out patient service, where are only 15 beds in this facility. About 35% of the Albanian population is under 19 years old (1.108.458) (14), which means that if we consider a minimum of 10% of children having a mental health problem, about 110.845 of the children are in need for mental health care.

Centers offering primary care and child consultation are widely dispersed and accessible, mostly in urban areas; however, communication between general practitioners and psychiatrists is usually infrequent. There is under diagnosis of and low use of specialist services. As a result, a small number of children with mental health problems have access to the appropriate services.

In Albania there has been almost no children and adolescents mental health research and there is a need for data to support services, a need on assessment as well as on epidemiological data relevant to local circumstances. The referral pathways taken by adult patients receiving services from a mental health professional in Albania have been documented in a collaborative study of the pathways of E-EPSI (15), but a study of pathways to psychiatric care for children and adolescents with mental health problems does not exist.

Materials and Method

The study of the help seeking process for children/adolescent was conducted in CAPC-UHC in Tirana, during September 2006-September 2007. The goal of the study was to investigate all the potential pathways to specialist services and their related factors. Our study focused on some specific questions concerning the referral process.

First, during a period of one year, which children/adolescents have had a new episode of mental health related problems and sought care to CAPC (Child Adolescent Psychiatry Clinic)?

Second, where do youngsters first enter the service system and what is the association between the relative intervals or delays and the time specialist services are actually received?

Third, given their point of entry, what are the patients' subsequent patterns of service use?

Finally, how does the severity of an individual's mental health problems and other demographic factors relate to their patterns of service use?

The study was approved by the Department of Neurosurgery-Neurology-Psychiatry, by Faculty of Medicine and by National Committee of Ethics on Research, and the Ministry of Health. Participants were children with age range of 2 to 17 years, as well as their parents (92% of cases had biological mothers). Children and their parents were informed about this study; written informed consent was duly taken from the parent accompanying the child in the CAPC.

The selection procedure interested a total of 932 medical visits performed at the CAPC in the one-year period (Sept. 2006 – Sept. 2007); the admission criteria for the study were age range of 2 to 17 years, and at least one single morbid episode requiring help at the CAPC. The exclusion criteria were as follows: age above 18 (although in Albania the CAPC cares for patients till their 21st birthday); age below 2 years was also excluded due to the extreme rarity of purely psychiatric problems; and those children whose relatives were explicitly requiring mainly (and/or simply) economic and financial aid (there is an applicable legislation in Albania that covers social assistance issues) were also excluded. Children suffering from mental retardation, with or without concomitant disorders, were also excluded from the study, because there is actually no standardized test for the Albanian population that would reliably evaluate the intelligence quotient of such a target group.

From the total of 932 children who visited the clinic during the study period, 665 children presented mental retardation, or their relatives were requiring economic aid and assistance; therefore, they were excluded from the study; 105 other cases did not comply with the age criteria; thus, 162 children formed the study group of the present work.

Questionnaires and interviews were completed by all the eligible children/adolescents and their parents. Encounter Form, previously used in the study of WHO (16) was utilized with some modifications regarding services and treatments for children. Children ( 11-17 years old) and parents of eligible children (4-17 years old) completed a child's and parent's Strengths and Difficulties Questionnaire (SDQ). The SDQ is a brief questionnaire that can be administered to parents and teachers of children 4 to 17 years, as well as to 11 to 17 years olds themselves (17, 18, and 19).

The encounter form gathers information on the socio-demographic characteristics of the participants and sources of care before they reach the mental health service. On the other hand, SDQ has been already translated in to more than 40 languages, and has been widely used to evaluate psychiatric morbidity in different settings, as part of a clinical workup, but also as a pure research tool (20, 21)

The questionnaires and forms were officially translated by professional translators and thereafter controlled through back-translation; yet no study has ever evaluated the psychometric properties, the reliability, the internal consistency, the cross-informant correlation and the retest stability of the questionnaires in their Albanian version. This drawback is considered a limitation of the present study; nevertheless, the encounter form was previously as well used in Albania in another study on pathways to care for psychiatric patients in south-east Europe (15).

The clinical diagnoses referred to in this paper are nearly all based on the diagnostic research criteria of ICD—10 (22) and were generated blindly to the SDQ scores. Children in risk of a psychopathology were not included in the analysis as they were not in a sufficient number to be analyzed.

The analysis in this paper is presented based on descriptive data only. The first part of the analysis includes results on the proportion of children/adolescents using the service, their demographic data, and the types and amounts of services they received. The socio-economic status of the family was evaluated based upon the self-declaring of the parent accompanying the child at the CAPC in terms of the annual income and of the job status inside the family (both parents unemployed; one unemployed; both employed). A great deal of the analysis focused on frequencies and descriptive statistics. The second part of the analysis dealt components such as the comparison of time intervals from the onset of the problem with the first time of seeking help, as well as finding correlations between the arrival of the patient at CAPC with the socio demographic factors of the case and the diagnostic group it pertained. Logistic regression was used to test associations and control confounding factors. P values were two tailed with alpha critical value at 0.05. Statistical analysis was done using SPSS 10 for Windows.

Results

A total of 162 eligible children (53.1% (86) male and 46.9% (76) female) were identified. 92% were self-described as white, 7.4% were self-described as being part of Egyptian ethnicity. The mean age of the total sample was 9.5+4.4 years, ranging from 2 to 17 years. On average, females were older (10.8+4.1 years) than males (8.3+4.3 years).

More than half of the children who participated in the study (76.5%) were living with both parents, 14.2% had divorced parents, and 5.6% had widowed parents. 61.7% of the sample were rated living in families of middle social class, while 17.3% were rated as living in families of below average social class (see table 1).

Table 1

Socio-demographic socioeconomic characteristics of the sample

Patients	Characteristics	No.
Child
Gender	53.1% males	86
	46.9% females	76
Age	Mean 9.5; 2-17; SD=4.4	162
Ethnicity	White 92.5%	149
	Egyptians 7.4%	12
Educational level (according to the classification of I S C E D, 1997 [29])	No education 31%	50
	Compulsory education 52%	84
	High school 17%	28
Parents
Marital status	Married 76.5%	124
	Divorced 14.2%	23
	Widowed 5.6%	9
Socio-economic status	Low 17.3%	28
	Middle 61.7%	100
	High 21%	34
Educational level (according to the classification of I S C E D, 1997 [29])	Pre-primary or primary education 21%	34
	Lower and upper secondary 57%	92
	Tertiary education 22%	36
Number of services used	One service 15.4%	25
	Two services 59.3%	96
	Three services 18.5%	30
	Four services 6.8%	11

The majority of children (90.1%) did not have any previous history of mental health services.

Of those children who had a previous psychiatric history, 33.3% had a depressive disorder, 40% had schizophrenia, and those having conduct disorders made up 12% of the study sample.

Of the total number of the subjects who sought care to CAPC, 55, 6% were referred to us by parents themselves, while the rest were either directed to us by other previous sources of care or came to us on their own initiative.

Family, relatives, and/or other close friends were predominantly the key persons for suggesting the first care seeking. The request for first care seek from children themselves was in 16.7% of those presented with depressive symptoms, 50% of those having abdominal pain and 7.7% of those having other somatic complaints.

40.7% of the sample was referred directly to the child neurologist of the UHCT (University Hospital Center Tirana) for first care seek; 16.7% sought first care from an adult psychiatrist; 14.8% sought first care from a GP; 4.9% from aurist doctor; 4.3% from a native healer; and 15.4% of the whole sample sought care directly from a child psychiatrist. Before arriving at the CAPS, some children who needed mental health service actually went to several other sources to seek care. Out of the total sample, 59.3% sought only one source of care before arriving to the specialized service for mental health problems; 15.4% of all the sample had direct access to CAPC; 18.5% sought care from two services before arriving at the CAPC; and 6.8% sought care from three services before arriving at the CAPC. A group of patients were referred to the CAPC after having some going back and forth from one service to another (child neurologist ⇔ GP).

The median interval between the beginning of the problem and first care seek was 46 weeks for the total sample. The most frequent diagnosis resulted to be pervasive developmental disorder (28.4%), phobic and anxiety disorders (19.1%), somatoform and dissociative disorders (17.3%), hyperkinetic and conduct disorder (15.4%) and movement disorders (4.9%).In terms of ‘first care seeking’ as any help-seeking behaviour such as referring to a general practitioner, psychological consultations, referring to any medical specialist all took place outside the CAPC. The interval from the onset of symptoms to the first visit at the CAPC was evaluated thereafter (see the discussion). Conversion related symptoms had shorter median interval between the onset of the problem and first seeking care (21-22 weeks), while hyperactivity problems had the longest median interval (52 weeks). The above data did not pertain to referral of the children at the CAPC, but at the first medical (psychological) center accessible to them.

The average time for the patients to first seek care until the time they received specialized services was studied, and it was noticed that this time was shorter for patients with cases of anxiety disorder and longer for those with conduct disorder. About half of the overall sample did not receive any medication from the first careers.

Out of the total number of patients who chose to be serviced by a GP as their first choice, 58.3% were referred to the specialist by the GP himself/herself. There was an important correlation between the gender and the length of interval from the onset of problem to the first career (F=10.803, p=0.001); as well as a significant correlation between the gender and the total interval of time from the onset of the problem, to the first visit at a specialist of child mental health (F=6.742, p=0.01). It was observed that girls have shorter intervals to the first career (22 weeks) compared to boys who have an interval from 62 weeks.

Discussion

This is the first study investigating the help seeking process to psychiatric care to Child and Adolescent Psychiatry in Tirana Albania.

In this study, we identified children/adolescents with a clinical psychiatric diagnosis that had been referred to CAPC during the period of one year, and we established an initial view of clearer and easier pathways for these patients to receive specialized care in CAPC, Tirana.

Help seeking process in child psychiatry Tirana has had mainly child neurologists as the key professionals to refer cases to the CAPC. Other than child neurologists, adult neuropsychiatrists (usually from cities other than Tirana as in such cities the chances of having a child psychiatrist are very low) have also referred many cases to the CAPC, as well as cases referred by GPs or even through direct access. A very low number of native or religious healers have been part of the pathway to care; however, they have not served as a main referral to a health care or to CAPC; thus, in a way becoming even a barrier for subjects to reach the necessary and effective mental health services.

The aurist resulted to be as a career in the help seeking care route, mainly to those with pervasive developmental disorders. The teachers’ referrals were not included in this analysis because there were only two cases (ADD) referred by them to seek care.

In contrast to Albanian adult pathway to care, the involvement of GPs in the help seeking process of care for children/adolescents with mental health problems to CAPC is higher and it can be explained. First, GP services (where we have included family doctors and pediatricians who are based within primary care) in Albania are closer (conveniently located) to children's residences and usually are the first point of contact when there is a need to provide health care for children. Second, recently there have been some changes in the organization of the public health sector, and due to health insurance rules, patients have to seek care from a health specialist via GP recommendations.

About half the number of GPs did not refer the children to CAPC, because they did not recognize the problem as psychiatric, and the pills prescribed by them mostly were aiming to treat physical symptoms. Non-recognition of mental health disorder by the GPs was one of the barriers in accessing effective specialist services. Another reason may be the mentality between doctors toward psychiatry and mental health problems. The psychiatrists’ role includes training, consultation, and supervision to develop the skills of primary care professionals. Enhancing primary care professionals’ ability to recognize and manage children's mental health problems is an important public health task in our country. At a population level, such an approach would potentially benefit a greater number of children, increase access to care, as well as enable a better match between the levels of need and service provision (3).

Parental awareness and demand for services play a crucial role in determining which children will need the services. Despite this, the majority of parents who have children with mental disorders do not perceive a problem (23, 24). Therefore, many affected children do not receive appropriate care. In the sample we studied, more than half of the parents were seeking themselves psychiatric care for their children, but they attended different services (mostly a child neurologist and/or a GP) before arriving at the CAPC. Such patterns of use from parents may be related to lack of knowledge on mental health problems.

The shortest interval from first seeking care to CAPC was for anxiety symptoms, while the longest was for conduct disorders; the ‘first seeking care to CAPC’ is considered the first referral to our service. In fact, children and parents might have been visited or consulted previously in a different center and in a different pattern (described above at the results). Such results mean that children presenting ‘conversion related symptoms’ have been well consulted early by a specialist, but have not been referred promptly to the CAPC; on the other hand, children presenting ‘anxiety related symptoms’ referred to the CAPC very quickly, thus sought specialized care early during their morbid situation. On the other side, hyperactivity problems were consulted lately in other non-specialistic settings; but conduct disorder was the nosology that showed the larger time delay from the onset of symptoms to the first visit at the CAPC.

There was a relationship between ‘gender’ and ‘median interval from the onset of problems to first seeking care’. According to the data, females have shorter intervals. There is a complicated relationship between socio-economic status and service use for mental health problems (25, 26, 27, 28). In our study, there was a statistical relationship between socio-economic status and service use. Based on results of this study, individuals pertaining to the middle socio-economic status group made the greatest use of CAPC services.

The main limitation of the study if that it offers information only for children that could access the psychiatric service at the CAPC in Tirana, which as a matter of fact, is the only university centre of child psychiatry in Albania; therefore cases having no possibility to access CAPC (for example, due to geographical distance) but treated elsewhere, were not part of the study. The study cannot offer any data for children with psychiatric co-morbidities who actually are treated at other centers. Since it was a single-centre based and pilot study, previous or alternative data from the same population are not available; actually no data are available regarding the prevalence of psychiatric disorders even for the adult Albanian population. Nevertheless, we have tried to impose findings inside the context, even through comparing similar studies that interested Albania as part of a larger discussion (15). Another limitation might be the self-declaring way of defining the initial date of the problem, since the cultural level and the strong stigma that accompanies the psychiatric issues will influence the answers collected.

This study focused on the process of seeking care only for children/adolescents who were newly referred to CAPC-the number is very low and we have no information about those not seen by us and that are in need of help. That's why there is a need for further research on a general population level, including primary care settings and preschool/school-based services. A clearer understanding about barriers to service use is required, as well as in identifying children/adolescents with psychiatric disorders not referred to specialists.

Conclusions

Based on the results of this study, several groups that needed intervention in order to increase child mental health service use were identified.

Such interventions may be:

1. at a practical level, mental health promotion and the provision of relevant information on children's mental health

2. at a public health perspective, where early identification and accessible services may reduce later complications

Educating parents about child psychopathology to raise their awareness of the possible presence of a disorder is crucial. Improving GP's skills in recognizing psychopathology and consequently facilitating referrals, thus accelerating access to specialized services is of utmost importance as well. Interventions may also be at a political level. Health field important decision makers can play a significantly important role in increasing the awareness about the magnitude and severity of problems related to mental disorders during childhood and adolescence. Their involvement would offer a huge support for the development of such greatly needed services.

Table 2

Mean intervals divided between diagnostic groups (Total sample size=162)

Diagnostic groups based on ICD-10 categories	% of patients with a given diagnosis	Interval before seeking care: weeks	Interval while receiving care: weeks	Total interval: weeks
Schizophrenia	3.1	55	36.6	91.6
Depression	7.4	23.7	11.4	35.1
ADD	12.1	49.6	11	60.6
Conduct disorders	4.3	61	64.5	125.5
Anxiety disorder	8	35	9	44
Panic disorder	2.5	24.5	34	58.5
Somatisation disorder	3.1	24	17	41
Conversion disorder	11.7	15	11	26
School phobia	2.5	129	15.7	144.7
Obssessive compulsive disorder	4.3	177.5	10.2	187.7
Pervasive developmental disorder	28.4	132	14	146
Tics disorders	4.9	77.7	10.8	88.5