Screening for mental health problems in urban preschool children – a pilot study

Objectives To assess prevalence and nature of mental health problems in preschool children and the feasibility and effectiveness of a screening tool for regular use by primary healthcare doctors in identifying these problems. Setting Colombo Municipal Council Child Welfare Centre – preschool clinics. Method Assessment tool was a semi-structured interview, which included a checklist of common symptoms of developmental, emotional and behaviour problems. Responses of the adult caregiver were recorded. Results Data of 120 children, 36-68 months of age, were available for analysis. Mild symptoms were present in 45.5% and definite or severe symptoms in 9.9%. A reliable positive correlation was found only between aggressive behaviour, disobedience and destructive behaviour (r= +0.66). There was low correlation between behaviour problems and eating problems and emotional symptoms (r= +0.11). Conclusion Rapid and effective screening was possible using the assessment tool, which can be used to improve recognition of mental health problem in preschoolers.


Introduction
Population studies show that prevalence of mental health problems among preschool children is about __________________________________________ 1 Senior Lecturer, Department of Psychological Medicine, Faculty of Medicine, University of Colombo. 2 Medical Officer, Colombo Municipal Council Public Health Services.
(Received on 10 December 2003)   21.4%, with 9.1% having severe problems 1 .It is also known that such problems are often dismissed as 'normal for age' or as difficulties they would 'grow out of' 1 .Low socioeconomic status and social deprivation make children more vulnerable to develop mental health problems 2,3,4,5 .Other known risk factors are family conflict, physical illness and relationship difficulties 1,6,7,8 .
This study involves preschool children living within the city of Colombo and attending clinics conducted at a Colombo Municipal Council Child Welfare Centre (CWC).Though the stresses of urban living and related adverse socio-economic and environmental factors often challenge these children, the epidemiology of mental health problems in this group is not known.Further, an effective structure for identification of such problems within the routine health care provision, is lacking.The need for such services is demonstrated in follow up studies where it is shown that behavioural and emotional problems in preschool children are stable over time and if untreated, continue into school age and beyond 9,10 .Hence, effective measures for early recognition, intervention and prevention should be in place within the existing system of healthcare for these children.We aim, in this study, to test a method of screening that may be used to recognize mental health problems in these children.There was a reliable correlation between aggressive behaviour, disobedience and destructive behaviour (r= +0.66).
There was no reliable correlation between behaviour problems and eating problems and emotional symptoms (r=+0.11) There was no reliable correlation between speech delay and behaviour problems (r= +0.19).
There was no reliable correlation between solitary behaviour and shyness (r= +0.49).
There was no reliable correlation of poor skills with speech and poor language comprehension (r= +0.53) There was no reliable correlation between refusal of food and other symptoms (r=0.17 or less).
Stressful family situations 63.6% did not report stressful situations at home.Among the rest, financial difficulties and excessive alcohol consumption in a family member was reported as the commonest causes of stress.

Illness in the child
76.8% did not report any physical illness.In the rest, illnesses related to the respiratory system were the commonest and were reported in 12.4% of children.
There was no statistically significant association found on cross tabulation, between symptoms of mental health problems and stress at home or physical illness in child (p >0.05).Statistically significant association was not found between behaviour problems and family size, mother's educational level or attendance /non-attendance at preschool (p >0.05).

Discussion
The study population of preschool children represents most others who attend CWCs in Colombo, in their economic and sociocultural mix.Hence, it may be reasonable to extend the results of this study to these geographical limits.Rapid administration of the screening schedule (8 minutes) was possible while covering a substantial area of inquiry about possible mental health problems in developmental, emotional and behavioural domains, and their social correlates.
Since the objective of the screening tool is to improve recognition of mental health problems, testing it across different social and ethnic subgroups might allow its use in a wider primary healthcare setting.
A two stage screening process for identification of cases was not considered in this study.This was because a doctor directly administered the checklist instead of parents being involved in an initial selfassessment.However, a two stage screening involving a primary healthcare doctor and a mental health professional would further validate the checklist and may avoid inclusion of false positives.
A further positive validity of the assessment is shown by its ability to detect known symptom clusters.For example, a reliable positive correlation is shown between aggressive, destructive, disobedient and restless behaviour, which is further supported by their low correlation with emotional symptoms.
Mild disruptive behaviour was seen in about 17% of children, which is known to represent a temperamental quality rather than a disorder 12,13,14 .However, such temperaments should be identified as they are vulnerability factors for both emotional and behavioural disorders in preschool children when under stress 15,16,17 .In addition, the persistence of these behaviours is apparent, as there is only a 9.7% reduction from 36-60 months of age.Feeding related problems were reported by over 50% of mothers and were consistently high through all age groups.Moderate to severe problems related to food intake is reported in 12% of preschoolers 11 .However, a very low correlation between eating behaviours and other symptoms (r=0.11)seen in this study indicates that the former is a stand-alone problem in these children.Hence, biased reporting by mothers due to culturally based preoccupation with feeding is a more likely explanation for the high prevalence, than a relationship to mental health.

Conclusion
Screening is necessary to detect mental health problems in preschool children, as parents are unlikely to voluntarily report them in contrast to physical problems.The results of this study show the need for a screening process in place in the CWCs and the training of doctors in basic mental health care for young children.

Table 1
Distribution of individual symptoms on checklist according to severity, age and sex 7,8,11hecklist of 18 common symptoms of mentalhealth problems, responses to each symptom being given as very true =2, somewhat true =1 or not true =0, depending on relevance of each symptom to child concerned.Items for checklist were identified from common presenting complaints of preschool children attending hospital based mental health clinics, and those documented in published literature7,8,11.Items in checklist fall into 3 distinct symptom domains viz. behaviour problems, emotional problems and developmental problems.The test-retest reliability of the assessment checklist, assessed on a sample of 15, was 98%.Inter-rater reliability was not assessed for this pilot study, as only a single assessor was involved.As the