J . Child Psychol. Psychiat., Vol. 17, 1976, pp. 79 to 83. Pergamon Press. Printed in Great Britain.
CHILD PSYCHIATRY IN DEVELOPING COUNTRIES KLAUS MINDE*
of child psychiatry in developing countries has shown a distinct pattern. Temporally, it has followed the estahlishment of adult psychiatric services. In Africa, South-East Asia and Latin America these hegan with the estahlishment of isolated mental hospitals 70 to 100 years ago and hecame part of general hospital carejust prior to World War II (German, 1972; Neki, 1973; Leon, 1973). Very little literature is availahle on the inception of childrens' services and there is no journal in the developing world which deals with the emotional needs of children. Yet in Africa and India, about which the author has personal knowledge, child psychiatric services have only heen developed during the past seven to eight years. This mirrors the development of child psychiatry in Europe and the U.S. (Kanner, 1964) as well as paediatrics in Africa (Weller, 1972) and is possihly related to the lack of lohhying power children have upon the deployment of scarce medical resources. There may he, however, another reason for the helated awareness of children's mental health needs. Psychiatry, like other aspects of Western medicine, was introduced to Africa and South-East Asia by the former colonial powers. Thus, initially, it was taught and practiced by Europeans who had an unavoidable ethnocentric bias and some reluctance to deal with disturbed children because their development appeared to be more enveloped in local traditions than the general functioning of their elders. They also generally did not speak the local languages and could never communicate directly with children, a problem less frequently encountered with adult patients. They may also have been influenced by the outward impression that Africans appear to treat their children like little adults, as they require domestic help from them early on, and thought that children in Africa do not require specialized services. It was thus only the emerging generation of indigenous psychiatrists who, knowing local developmental and child rearing practices, could begin to provide some services to children. For example, German (1972) in a paper summarizing presently available data on clinical adult psychiatry in sub-Saharan African, gives 91 references of which only 18 (20%) have at least one African co-author. A recent review of clinical work in child psychiatry (Minde, 1974a) cites only 16 references of which, however, eight (50%) were written by Africans. What then are these child psychiatric services and what data have they provided ? Here again, one has to evaluate the facts in a historical perspective. Psychiatry, both in Africa and South-East Asia was strongly influenced by British psychiatry (German, 1972; Neki, 1973). At the time this occurred this meant emphasis on phenomenology and primarily organic modes of treatment. British psychiatry furthermore had close ties with neurology and traditionally did not emphasize psychodynamic principles. This trend is shown in child psychiatry in developing THE GROWTH
•The Hospital for Sick Children, Toronto, Canada. 79
80
KLAUS MINDE
countries and is enhanced by the enormous populations which have to be served with a mere handful of trained personnel. Reports from both Africa and SouthEast Asia (Hoch, 1967; Hazera, 1972; Izuora, 1970, 1972; Asuni, 1970; Rahim, 1972; Ramanujam, 1968) cite flgures of patients who have been seen in various clinics but also talk about the general inadequacy of services. For example, Asuni (1970) stressed that his clinic was one of only two facilities in Nigeria with a population of at least 30 million children under the age of 14, while others stated that there are only about 75 child guidance clinics and six trained child psychiatrists in India (Marfatia, 1973; Ramanujam, 1975). The type of patients seen by these clinics is difficult to evaluate as most writers give only a very general description, at times not even citing age, sex and diagnosis. Most authors also fail to state the criteria which made them apply the stated diagnosis. This leads to a tremendous variation in the presented clinical material. For example, Goodall (1972) described seven particular cases of emotionally disturbed children met in a general paediatric outpatient clinic in Kampala, Uganda, but gave no indication of the general rate of emotional disorders among her clinic population. Rahim (1972) reviewed the clinical diagnoses of 319 children seen in Port Sudan over a six-year period. He claims that 31% of his child patients had a psychoneurotic disorder, 30% primary epilepsy, 24% schizophrenia, and 7-5% each were retarded and enuretic. About 60% of his population was aged 11-15, the rest younger. His data thus represent a high number of schizophrenic and neurotic children in a relatively young population and includes no children with behaviour disorders. Adomakoh (1973) in his report from Ghana diagnosed 60% of his patients as either retarded or epileptic, 15% as psychotic and 24% as neurotic. Under the latter category he included children who presented with study problems and who complained of a variety of symptoms associated with muscle tension such as headaches, pain in the eyes, chest or abdomen. This cluster of symptoms was first described by Prince (1960) in Nigeria, confirmed by Mbanefo (1966) and German etal. (1970) in Uganda and has been called the "brain fag syndrome". None of the above authors, however, nor a recent more psychodynamically orientated investigation into the brain fag syndrome (Minde, 1974b) would have labelled these youngsters as 'neurotic' as defined fly any of the standard psychiatric nomenclatures. In contrast to the data of Rahim (1972) and Adomakoh (1973), Isuora (1972) described only 6-5% of his children as suffering from "neuroticism" but included general speech disorders (10%) and deafness (12%) among his psychiatric diagnoses. Some authors have written about specific psychiatric conditions, although here again the operational definition of the condition in question is variable. Longe (1972) described in detail four autistic children in her clinic in Lagos. She found family characteristics in her sample which were dramatically similar to those described in the Western literature (Rutter, 1968). Ortiguez et al. (1965) discussed 14 cases of juvenile delinquency in Dakar and related the increase of this problem in this city to the loss of the urban child's collective identification with his extended family. This loss, according to Ortiguez, is then counteracted by the child's identification with the delinquent gang. Okasha et al. (1972) described the symptomatology of 134 depressed children seen in Cairo over a three year period. The authors differentiated between children who were "phobic", "enuretic" and "manic
ANNOTATIONS
81
depressive" and those labelled "depressives". The symptoms leading to their respective diagnoses such as "difficulties at school", "immaturity", "lack of confidence", or "warm personality" were not operationally defined and hence remain of uncertain validity. Ibrahim (1973) reported on 24 children who refused to go to school, seen over four years in Khartoum. He found 65% of the children's mothers to be over-protective and 60% of them to live away from their fathers. As no control data are given, the figures have only a limited meaning. Despite the great variability in the literature discussed above, four common themes nevertheless emerge. The most uniform observation, made by both African and South-East Asian child psychiatrists, is the high percentage of children who present with symptoms of mental retardation and epilepsy. Figures here range from 37% of all clinic patients (Rahim, 1972) to 55% (Minde, 1974a) and 60% (Izuora, 1972). The second common theme is the high percentage of retardation secondary to infections and trauma among the retarded patients. In Ramanujam and David's data (1969) from India only 38% of the retarded children were classified as suffering from primary retardation and Minde (1974a) reported this group to contain only 29% of his population. These results are undoubtedly a reflection of the high rate of central nervous system infections among children in these countries. The third common observation is that children brought to psychiatric clinics are mainly adolescent or in the immediate pre-adolescent period. Most authors deal almost exclusively with children above the age of ten and some specify an even older group (Hazera, 1972). The last generalization one can make from the presented data is the low number of children who are brought to clinics because of general behaviour or acting out disorders. No study reports such problems in more than 30% of their clinic population and in few studies does one find any specific mention of acting out disorders (5-5% by Izuora, 1972; 3 % by Adamakoh, 1973; 14% by Minde, 1975b; 8% by Ramanujam, 1968). There is, however, a fairly high percentage of children who present with psychosomatic disorders (20% Ramanujam, 1968; 10% Minde, 1974a). Having looked at some clinic samples of psychiatrically disturbed children the question arises as to what extent this population is representative of the incidence of psychiatric morbidity in the general population. Here data becomes less extensive for Africa and none are available for South-East Asia. Giel et al. (1969) studied the psychiatric morbidity of two Ethiopian villages. They found 3-4% of all children under the age of nine and 10% of those ten years and older to show psychological abnormalities. No detailed breakdown of symptomatology was given. Minde (1974a, 1975a) examined the incidence of psychiatric difficulties in various child populations in Uganda more systematically. He found the global incidence of psychiatric disturbance in primary school children to be 18% with a high of 24% in an urban setting and 10-5% in a rural area. Gederblad (1968) focused on specific psychological symptoms in children. She screened all 1716 children aged 3-15 who lived in a Sudanese village with respect to stuttering, sleep walking, enuresis, encopresis and sleep disturbances. Ghildren showing more than one of the above symptoms and a Swedish control group were then studied in more detail. Gederblad found the Sudanese children to have a generally lower rate of severe symptoms than those of the Swedish sample (8 vs 25%). The Sudanese, however, showed a higher in-
82
KLAUS MINDE
cidence of aggression and nocturnal enuresis than their Swedish controls. While Cederblad used a questionnaire which had not been validated to denote definite psychopathology Minde in his Ugandan studies used a validated symptom screening instrument (Rutter, 1966), a known parental symptom check list (Peterson and Quay, 1967) and an accredited child psychiatric classification (GAP, 1966). His results (Minde, 1975h) showed these instruments to possess strong transcultural relevance. His data also demonstrated that many interpersonal and social risk factors associated with psychiatric disorders in the West, such as a hroken home, frequent moves and general poverty are equally powerful concomitants of maladjustment in developing countries. While the availahle literature gives a fair estimate of the problems child psychiatrists face in Africa and South-East Asia, the delivery of services to the patients and the teaching of child psychiatry has received very little scrutiny. Neki (1973) cites some reported data which reflect the very few hours given to teaching in psychiatry at various medical schools in South-East Asia. No such figures are available for child psychiatry. This most likely reflects the almost total absence of any such teaching, including the instruction in general growth and development to medical students, and more importantly, to paramedical personnel. The clinical data referred to previously indicate clearly that hospital child psychiatry in Africa and South-East Asia deals primarily with children of the professional city class (Hazera, 1972; Minde, 1974a), those who have organic impairments and those with psychosomatic complaints. It is these latter two conditions which are perceived as "medical" by the average citizen and brought to clinics. Children with general behaviour disorders, learning difficulties and anti-social activities are not usually brought to a hospital but sent to indigenous healers (35% of all children seen by the author in Uganda had flrst been seen by a healer and 35 % were investigated by the author and a healer simultaneously) or else simply expelled from school or severely punished (Minde, 1975c). It is these children who should and can be treated by paramedical personnel in the community as there is a very strong reluctance among medical personnel to forego the convenience of hospital oflices in lieu of community medicine (Minde, 1975c). The achievement of this goal, however, requires the incorporation of knowledge about child development and specific behavioural abnormalities into the teaching programme of medical and public health assistants as well as teachers. In no African or South-East Asian country has this been implemented systematically. This leaves almost all disturbed children in Africa and South-East Asia without any professional assistance. REFERENCES ADOMAKOH, C . C . (1973) The disturbed child in Ghana. Paper presented at Association of Psychiatrists in Africa Workshop, 13-19 September. ASUNI, T . (1970) Problems of child guidance of the Nigerian school child. W. Afric. J. Educ. 14,49-55. CEDERBLAD, M . (1968) A child psychiatric study on Sudanese Arab children. Acta Psychiat. Scand. Suppl. 200, 1-230. GAP (1966) Psychopathological disorders in childhood: theoretical considerations and a proposed classification. Group for the Advancement of Psychiatry. Vol. IV. Report No. 62. GERMAN, G . A., ASSAEL, K . and MUHANGI, J. (1970) Psychiatric disorders associated with study in the mid-adolescent years. Proc. 2nd Pan African Psychiatric Workshop, pp. 131-135. Mauritius.
ANNOTATIONS
83
GERMAN, G . A. (1972) Aspects of clinical psychiatry in sub-Saharan Africa. Br. J. Psychiat. 121, 461-479. GIEL, R . , BISHAW, M . and VAN LUIJK, J. N. (1969) Behaviour disorders in Ethiopian children. Psychiat. Neurol. Neurochir. 72, 395-400. GOODALL, J. (1972) Emotionally induced illness in East African children. E. Afric. Med. J. 49, 407418. HAZERA (1972) Study of a children population. Paper presented at the Zrd Pan-African Psychiatric Congress, Khartoum, November. HOCH, E . M . (1967) Indian children on a psychiatrist's playground. Indian Coimcil of Medical Research, New Delhi. IBRAHIM, H . H . A. (1973) School refusal among Sudanese children. Paper presented at Assoc. of Psychiatrists in Africa Workshop, 13-19 September. IZUORA, G . E . A. (1970) Mental health of children in developing countries. Proc. 2nd Pan-African Psychiatric Workshop, pp. 59-65. Mauritius. IZUORA, G . E . A. (1972) The Enugu child guidance clinic: its organization and growth tendency. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. KANNER, L . (1964) A History of the Care and Study of the Mentally Retarded. Thomas, II. LONGE, C . I. (1972) Four cases of infantile autbm in Nigerian children. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. LEON, C . A. (1972) Psychiatry in Latin America. Br. J. Psychiat. 121, 121-136. MARFATIA, J. C. (1973) Psychiatric services for children in India. Child Psychiat. Q..6, 10-29. MBANEFO, S. E . (1966) Heat in the body as a psychiatric symptom. J . Coll. General Practitioners 11, 235-240. MINDE, K . (1974a) The first 100 cases of a child psychiatric clinic in Uganda: a follow-up investigation. East Afric. J. Med. Res. 1, 95-106. MINDE, K . (1974b) Study problems in Ugandan Secondary School Students: a controlled evaluation. Br. J. Psychiat. 125, 131-137. MINDE, K . (1975a) Psychological problems in Ugandan school children: a controlled evaluation. J . Child Psychol. Psychiat. 16, 49-59. MINDE, K . (1975b) Children in Uganda: Rates of behavioural deviations and psychiatric disease in various school and clinic populations. Submitted for publication. MINDE, K . (1975C) Ghild psychiatry in developing countries: some lessons learned. East Afric. J. Med. Res. in press. NEKI, J. S. (1973) Psychiatry in South-East Asia. Br. J . Psychiat. 123, 257-269. OKASHA, H . , KAMEL, H . and EL-ESSAWI, M . (1972) Presentation of depression in Egyptian children. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. ORTIGUES, M . - G . , COLOT, A. and MONTAGNIER, M . T . (1965) La ddlinquance juvdnile a Dakar.
Etude psychologique de 14 cas. Psychopath. Africaine 1, 85-129. PETERSON, P. R. and QUAY, H . C . (1967) Faster analyzed Problem Checklist. Urbana, II., University of Illinois, Children's Research Center. PRINCE, R . H . (1960) The "brain fag" syndrome in Nigerian students. J. Ment. Sci. 106, 559-570. RAHIM, T . H . (1972) Psychiatric disorders in the Red Sea children. Paper presented at the 3rd PanAfrican Psychiatric Congress, Khartoum, November. RAMANUJAM, B . K . (1968) Behaviour disorders of school going children. Arch. Child Hlth 10, 48-60. RAMANUJAM, B . K . and DAVID, S. (1969) A clinical study of 100 cases of mentally retarded children seen in a clinic for the mentally retarded. Ind. Pediat. 6, 118-131. RAMANUJAM, B. K . (1975) Personal communication. RUTTER, M . (1967) A children's behaviour questionnaire for completion by teachers: preliminary findings. J . Child Psychot. Psychiat. 8, 1-11. RUTTER, M . (1968) Concepts of autism: a review of research. J. Child Psychol. Psychiat. 9, 1-25. WELLER, S. D . V. (1972) The hospital care of East African children: the problems defined. J . Trop. Paed. 18, 5-12.
CHILD PSYCHIATRY IN DEVELOPING COUNTRIES KLAUS MINDE*
of child psychiatry in developing countries has shown a distinct pattern. Temporally, it has followed the estahlishment of adult psychiatric services. In Africa, South-East Asia and Latin America these hegan with the estahlishment of isolated mental hospitals 70 to 100 years ago and hecame part of general hospital carejust prior to World War II (German, 1972; Neki, 1973; Leon, 1973). Very little literature is availahle on the inception of childrens' services and there is no journal in the developing world which deals with the emotional needs of children. Yet in Africa and India, about which the author has personal knowledge, child psychiatric services have only heen developed during the past seven to eight years. This mirrors the development of child psychiatry in Europe and the U.S. (Kanner, 1964) as well as paediatrics in Africa (Weller, 1972) and is possihly related to the lack of lohhying power children have upon the deployment of scarce medical resources. There may he, however, another reason for the helated awareness of children's mental health needs. Psychiatry, like other aspects of Western medicine, was introduced to Africa and South-East Asia by the former colonial powers. Thus, initially, it was taught and practiced by Europeans who had an unavoidable ethnocentric bias and some reluctance to deal with disturbed children because their development appeared to be more enveloped in local traditions than the general functioning of their elders. They also generally did not speak the local languages and could never communicate directly with children, a problem less frequently encountered with adult patients. They may also have been influenced by the outward impression that Africans appear to treat their children like little adults, as they require domestic help from them early on, and thought that children in Africa do not require specialized services. It was thus only the emerging generation of indigenous psychiatrists who, knowing local developmental and child rearing practices, could begin to provide some services to children. For example, German (1972) in a paper summarizing presently available data on clinical adult psychiatry in sub-Saharan African, gives 91 references of which only 18 (20%) have at least one African co-author. A recent review of clinical work in child psychiatry (Minde, 1974a) cites only 16 references of which, however, eight (50%) were written by Africans. What then are these child psychiatric services and what data have they provided ? Here again, one has to evaluate the facts in a historical perspective. Psychiatry, both in Africa and South-East Asia was strongly influenced by British psychiatry (German, 1972; Neki, 1973). At the time this occurred this meant emphasis on phenomenology and primarily organic modes of treatment. British psychiatry furthermore had close ties with neurology and traditionally did not emphasize psychodynamic principles. This trend is shown in child psychiatry in developing THE GROWTH
•The Hospital for Sick Children, Toronto, Canada. 79
80
KLAUS MINDE
countries and is enhanced by the enormous populations which have to be served with a mere handful of trained personnel. Reports from both Africa and SouthEast Asia (Hoch, 1967; Hazera, 1972; Izuora, 1970, 1972; Asuni, 1970; Rahim, 1972; Ramanujam, 1968) cite flgures of patients who have been seen in various clinics but also talk about the general inadequacy of services. For example, Asuni (1970) stressed that his clinic was one of only two facilities in Nigeria with a population of at least 30 million children under the age of 14, while others stated that there are only about 75 child guidance clinics and six trained child psychiatrists in India (Marfatia, 1973; Ramanujam, 1975). The type of patients seen by these clinics is difficult to evaluate as most writers give only a very general description, at times not even citing age, sex and diagnosis. Most authors also fail to state the criteria which made them apply the stated diagnosis. This leads to a tremendous variation in the presented clinical material. For example, Goodall (1972) described seven particular cases of emotionally disturbed children met in a general paediatric outpatient clinic in Kampala, Uganda, but gave no indication of the general rate of emotional disorders among her clinic population. Rahim (1972) reviewed the clinical diagnoses of 319 children seen in Port Sudan over a six-year period. He claims that 31% of his child patients had a psychoneurotic disorder, 30% primary epilepsy, 24% schizophrenia, and 7-5% each were retarded and enuretic. About 60% of his population was aged 11-15, the rest younger. His data thus represent a high number of schizophrenic and neurotic children in a relatively young population and includes no children with behaviour disorders. Adomakoh (1973) in his report from Ghana diagnosed 60% of his patients as either retarded or epileptic, 15% as psychotic and 24% as neurotic. Under the latter category he included children who presented with study problems and who complained of a variety of symptoms associated with muscle tension such as headaches, pain in the eyes, chest or abdomen. This cluster of symptoms was first described by Prince (1960) in Nigeria, confirmed by Mbanefo (1966) and German etal. (1970) in Uganda and has been called the "brain fag syndrome". None of the above authors, however, nor a recent more psychodynamically orientated investigation into the brain fag syndrome (Minde, 1974b) would have labelled these youngsters as 'neurotic' as defined fly any of the standard psychiatric nomenclatures. In contrast to the data of Rahim (1972) and Adomakoh (1973), Isuora (1972) described only 6-5% of his children as suffering from "neuroticism" but included general speech disorders (10%) and deafness (12%) among his psychiatric diagnoses. Some authors have written about specific psychiatric conditions, although here again the operational definition of the condition in question is variable. Longe (1972) described in detail four autistic children in her clinic in Lagos. She found family characteristics in her sample which were dramatically similar to those described in the Western literature (Rutter, 1968). Ortiguez et al. (1965) discussed 14 cases of juvenile delinquency in Dakar and related the increase of this problem in this city to the loss of the urban child's collective identification with his extended family. This loss, according to Ortiguez, is then counteracted by the child's identification with the delinquent gang. Okasha et al. (1972) described the symptomatology of 134 depressed children seen in Cairo over a three year period. The authors differentiated between children who were "phobic", "enuretic" and "manic
ANNOTATIONS
81
depressive" and those labelled "depressives". The symptoms leading to their respective diagnoses such as "difficulties at school", "immaturity", "lack of confidence", or "warm personality" were not operationally defined and hence remain of uncertain validity. Ibrahim (1973) reported on 24 children who refused to go to school, seen over four years in Khartoum. He found 65% of the children's mothers to be over-protective and 60% of them to live away from their fathers. As no control data are given, the figures have only a limited meaning. Despite the great variability in the literature discussed above, four common themes nevertheless emerge. The most uniform observation, made by both African and South-East Asian child psychiatrists, is the high percentage of children who present with symptoms of mental retardation and epilepsy. Figures here range from 37% of all clinic patients (Rahim, 1972) to 55% (Minde, 1974a) and 60% (Izuora, 1972). The second common theme is the high percentage of retardation secondary to infections and trauma among the retarded patients. In Ramanujam and David's data (1969) from India only 38% of the retarded children were classified as suffering from primary retardation and Minde (1974a) reported this group to contain only 29% of his population. These results are undoubtedly a reflection of the high rate of central nervous system infections among children in these countries. The third common observation is that children brought to psychiatric clinics are mainly adolescent or in the immediate pre-adolescent period. Most authors deal almost exclusively with children above the age of ten and some specify an even older group (Hazera, 1972). The last generalization one can make from the presented data is the low number of children who are brought to clinics because of general behaviour or acting out disorders. No study reports such problems in more than 30% of their clinic population and in few studies does one find any specific mention of acting out disorders (5-5% by Izuora, 1972; 3 % by Adamakoh, 1973; 14% by Minde, 1975b; 8% by Ramanujam, 1968). There is, however, a fairly high percentage of children who present with psychosomatic disorders (20% Ramanujam, 1968; 10% Minde, 1974a). Having looked at some clinic samples of psychiatrically disturbed children the question arises as to what extent this population is representative of the incidence of psychiatric morbidity in the general population. Here data becomes less extensive for Africa and none are available for South-East Asia. Giel et al. (1969) studied the psychiatric morbidity of two Ethiopian villages. They found 3-4% of all children under the age of nine and 10% of those ten years and older to show psychological abnormalities. No detailed breakdown of symptomatology was given. Minde (1974a, 1975a) examined the incidence of psychiatric difficulties in various child populations in Uganda more systematically. He found the global incidence of psychiatric disturbance in primary school children to be 18% with a high of 24% in an urban setting and 10-5% in a rural area. Gederblad (1968) focused on specific psychological symptoms in children. She screened all 1716 children aged 3-15 who lived in a Sudanese village with respect to stuttering, sleep walking, enuresis, encopresis and sleep disturbances. Ghildren showing more than one of the above symptoms and a Swedish control group were then studied in more detail. Gederblad found the Sudanese children to have a generally lower rate of severe symptoms than those of the Swedish sample (8 vs 25%). The Sudanese, however, showed a higher in-
82
KLAUS MINDE
cidence of aggression and nocturnal enuresis than their Swedish controls. While Cederblad used a questionnaire which had not been validated to denote definite psychopathology Minde in his Ugandan studies used a validated symptom screening instrument (Rutter, 1966), a known parental symptom check list (Peterson and Quay, 1967) and an accredited child psychiatric classification (GAP, 1966). His results (Minde, 1975h) showed these instruments to possess strong transcultural relevance. His data also demonstrated that many interpersonal and social risk factors associated with psychiatric disorders in the West, such as a hroken home, frequent moves and general poverty are equally powerful concomitants of maladjustment in developing countries. While the availahle literature gives a fair estimate of the problems child psychiatrists face in Africa and South-East Asia, the delivery of services to the patients and the teaching of child psychiatry has received very little scrutiny. Neki (1973) cites some reported data which reflect the very few hours given to teaching in psychiatry at various medical schools in South-East Asia. No such figures are available for child psychiatry. This most likely reflects the almost total absence of any such teaching, including the instruction in general growth and development to medical students, and more importantly, to paramedical personnel. The clinical data referred to previously indicate clearly that hospital child psychiatry in Africa and South-East Asia deals primarily with children of the professional city class (Hazera, 1972; Minde, 1974a), those who have organic impairments and those with psychosomatic complaints. It is these latter two conditions which are perceived as "medical" by the average citizen and brought to clinics. Children with general behaviour disorders, learning difficulties and anti-social activities are not usually brought to a hospital but sent to indigenous healers (35% of all children seen by the author in Uganda had flrst been seen by a healer and 35 % were investigated by the author and a healer simultaneously) or else simply expelled from school or severely punished (Minde, 1975c). It is these children who should and can be treated by paramedical personnel in the community as there is a very strong reluctance among medical personnel to forego the convenience of hospital oflices in lieu of community medicine (Minde, 1975c). The achievement of this goal, however, requires the incorporation of knowledge about child development and specific behavioural abnormalities into the teaching programme of medical and public health assistants as well as teachers. In no African or South-East Asian country has this been implemented systematically. This leaves almost all disturbed children in Africa and South-East Asia without any professional assistance. REFERENCES ADOMAKOH, C . C . (1973) The disturbed child in Ghana. Paper presented at Association of Psychiatrists in Africa Workshop, 13-19 September. ASUNI, T . (1970) Problems of child guidance of the Nigerian school child. W. Afric. J. Educ. 14,49-55. CEDERBLAD, M . (1968) A child psychiatric study on Sudanese Arab children. Acta Psychiat. Scand. Suppl. 200, 1-230. GAP (1966) Psychopathological disorders in childhood: theoretical considerations and a proposed classification. Group for the Advancement of Psychiatry. Vol. IV. Report No. 62. GERMAN, G . A., ASSAEL, K . and MUHANGI, J. (1970) Psychiatric disorders associated with study in the mid-adolescent years. Proc. 2nd Pan African Psychiatric Workshop, pp. 131-135. Mauritius.
ANNOTATIONS
83
GERMAN, G . A. (1972) Aspects of clinical psychiatry in sub-Saharan Africa. Br. J. Psychiat. 121, 461-479. GIEL, R . , BISHAW, M . and VAN LUIJK, J. N. (1969) Behaviour disorders in Ethiopian children. Psychiat. Neurol. Neurochir. 72, 395-400. GOODALL, J. (1972) Emotionally induced illness in East African children. E. Afric. Med. J. 49, 407418. HAZERA (1972) Study of a children population. Paper presented at the Zrd Pan-African Psychiatric Congress, Khartoum, November. HOCH, E . M . (1967) Indian children on a psychiatrist's playground. Indian Coimcil of Medical Research, New Delhi. IBRAHIM, H . H . A. (1973) School refusal among Sudanese children. Paper presented at Assoc. of Psychiatrists in Africa Workshop, 13-19 September. IZUORA, G . E . A. (1970) Mental health of children in developing countries. Proc. 2nd Pan-African Psychiatric Workshop, pp. 59-65. Mauritius. IZUORA, G . E . A. (1972) The Enugu child guidance clinic: its organization and growth tendency. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. KANNER, L . (1964) A History of the Care and Study of the Mentally Retarded. Thomas, II. LONGE, C . I. (1972) Four cases of infantile autbm in Nigerian children. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. LEON, C . A. (1972) Psychiatry in Latin America. Br. J. Psychiat. 121, 121-136. MARFATIA, J. C. (1973) Psychiatric services for children in India. Child Psychiat. Q..6, 10-29. MBANEFO, S. E . (1966) Heat in the body as a psychiatric symptom. J . Coll. General Practitioners 11, 235-240. MINDE, K . (1974a) The first 100 cases of a child psychiatric clinic in Uganda: a follow-up investigation. East Afric. J. Med. Res. 1, 95-106. MINDE, K . (1974b) Study problems in Ugandan Secondary School Students: a controlled evaluation. Br. J. Psychiat. 125, 131-137. MINDE, K . (1975a) Psychological problems in Ugandan school children: a controlled evaluation. J . Child Psychol. Psychiat. 16, 49-59. MINDE, K . (1975b) Children in Uganda: Rates of behavioural deviations and psychiatric disease in various school and clinic populations. Submitted for publication. MINDE, K . (1975C) Ghild psychiatry in developing countries: some lessons learned. East Afric. J. Med. Res. in press. NEKI, J. S. (1973) Psychiatry in South-East Asia. Br. J . Psychiat. 123, 257-269. OKASHA, H . , KAMEL, H . and EL-ESSAWI, M . (1972) Presentation of depression in Egyptian children. Paper presented at the 3rd Pan-African Psychiatric Congress, Khartoum, November. ORTIGUES, M . - G . , COLOT, A. and MONTAGNIER, M . T . (1965) La ddlinquance juvdnile a Dakar.
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