Psychiatric disorders of children are a recognized public health problem which has contributed significantly to disability and mortality, as well as an exacerbation of other medical conditions [1]. According to the Global Burden of Disease (GBD), mental illnesses constitute 10.5% of GBD, which may rise up to 15% in the year 2020 [2]. According to the World Health Organization (WHO), mental health disorders are one of the leading causes of disability worldwide [2]. In developing countries like Pakistan, one percent of the population suffers from severe and 10% from mild mental disorders, although epidemiological data regarding mental illnesses is lacking in Pakistan [3].

In Pakistan, only two epidemiological studies have been conducted which addresses behavioral problems in children and adolescents. A mainstream-school based study estimated 34% prevalence of behavioral problems among 5 - 11 years children in Karachi [4] , whereas the other study was conducted in orphanages of Karachi among 4 - 16 years old children and indicated a prevalence of behavioral problems as 33% [5]. Literature suggested that, people do not seek treatment for psychiatric illnesses in Pakistan, and one of the reasons is being taboo/social stigma attached with it, or people consider psychiatric problems as supernatural evil forces [3] [4] [5] [6]. Therefore, even if mental health facilities are available, these are underutilized. However, in case of children, mental health services are scarce in Pakistan [7]. The other reason for ignorance of children’s psychiatric conditions in Pakistan might be due to child’s inability to explain their feelings/problems as compared to adults. Furthermore, if a child has communication problems such as hearing-impairment, it will be more difficult to express his/her feelings [8].

Literature suggests that hearing impairment has its medical as well as social aspects. It can slow down children’s progress in schools and can place them in social isolation [2]. There is a correlation between hearing impairment and psychiatric disorders among children and adolescents [8].

However, the aspect of mental health among hearing-impaired children has not been given due attention in Pakistan, and there is no established prevalence of psychiatric disorders among this population in the country [7] [8]. It is possible that in Pakistan, population with deafness could be large, because consanguinity is common in the country. Consanguinity is a dominant cause of profound sensorineural deafness in Pakistan. Evidence shows that profound hearing-impairment is more prevalent in countries where consanguineous marriages are common. In Khyber Pakhtunkhwa province of Pakistan, prevalence of consanguinity is reported to be 60%, but unfortunately there is little published information on deafness in Pakistan [9]. Therefore, the aim of this study was to estimate the prevalence of psychiatric disorders among hearing-impaired children aged 4 - 16 years attending special education institutions in Karachi and to identify associated socio-demographic characteristics of children and parents.

(Table 1) A total of 272 hearing-impaired-children aged 4 - 16 years were selected from two special education institutions, Ida-Rieu-academy (n = 113) and Dewa-academy (n = 159), with the response rate of 91%., Children in Ida-Rieu

¹Tests P-value of continuous variables was obtained from t-test for two independent samples, and P-value for categorical variables was obtained from Pearson’s Chi Square Test or Fisher’s Exact Test, where appropriate. *P-value significant at 5% significance level; ²Matric is 10 years of school education in Pakistani educational system, and primary is 5 years of school education in Pakistani educational system. ³One US Dollar = 86.45 Pak Rupees at the time the study was conducted.

were older (11.3 ± 3.4 years vs. 10.1 ± 3.1 years) and had better school performances (24.0% poor performance) as compared to children in Dewa-academy (45.3% poor performance). Parents of Dewa-academy (42.1% mothers & 49.1% fathers had qualification above matric) were more educated than those of Ida-Rieu (9.7% mothers & 22.1% fathers had qualification above matric). Likewise 17.0% parents in Dewa-academy and 5.3% in Ida-Rieu had monthly income of ≥28,000 Pak rupees. Other demographic characteristics of study population are summarized in Table 1.

(Table 2) Parent and teacher ratings of children for psychiatric problems on SDQ composite scale, and on its subscales are reported in Table 2. On SDQ-composite scale, teacher-rated prevalence 32.7% 95% CI (30%, 36%) is greater than parent-rated prevalence 18%; 95% CI (15%, 21%). Kappa statistics and its P-value indicates poor agreement (Kappa = 0.094, P-value = 0.095). Similarly on conduct problems subscale, parents rated 37.1% (95% CI: 32, 42) children, whereas teachers rated 40.4% (95% CI: 36, 44) children as abnormal; although P-value is highly significant but Kappa statistic value denotes poor agreement (Kappa = 0.173, P-value = 0.004). P-values of Kappa statistic for emotional symptom scale, hyperactivity scale, peer problem scale and pro-social symptom scale indicated no significant agreement between parent and teacher ratings.

(Table 3) Multivariable logistic regression model was made to assess an association of various predictors to parent-rated psychiatric problems of children. We found that the odds of psychiatric problems in hearing-impaired-children with poor class performance AOR: 3.43; 95% CI (1.17, 10.04) and good performance AOR: 3.09; 95% CI (1.04, 9.25) are about 3-folds than that for an outstanding/excellent class performance. Furthermore, late diagnosis of hearing impairment after 6 months of age had a protective effect on psychiatric problems

¹Kappa Statistics, <0.4 denotes poor/marginal agreement/reproducibility, 0.4 - 0.75 denotes good agreement/reproducibility, >0.75 denotes excellent agreement/reproducibility; ²P-value is testing the null hypothesis Ho: Kappa = 0, *P-value significant at 5% significance level; ³Composite Scale comprised of ESS, CPS, HS, and PPS.

*It was assessed by class teacher. Adjusted for; child age, child gender, child educational class, child hearing impairment degree, child cause of hearing impairment, child use of hearing aid, parent marital status, parent (mother and father) age, parent (mother and father) hearing impairment status, parent (mother and father employment status, blood relation with spouse, number of children/family, number of hearing impaired children/family, total members at home, responding parent, earning members at home, institution.

as compared to children diagnosed at or before 6 months AOR: 0.49; 95% CI (0.25, 0.96). Interestingly, mother’s lack of education showed a protective effect for psychiatric problems as children of illiterate mothers AOR: 0.27; 95% CI (0.10, 0.76) and primary-matric educated mothers AOR: 0.33; 95% CI (0.13, 0.82) were at lesser risk for psychiatric problems relative to children of above matric-qualified mothers. On the other hand, odds of psychiatric problems in children with illiterate fathers AOR: 4.05; 95% CI (1.36, 12.07) and primary-matric educated fathers AOR: 2.63; 95% CI (1.06, 6.52) were considerably greater than that for above-matric qualified fathers. Moreover, odds of psychiatric problems in children of a depressed parent were about 3 times AOR: 2.61; 95% CI (1.34, 5.11) the odds of psychiatric problems of in children of a non-depressed parent.

(Table 4) Factor analysis was performed for parent-rated SDQ. Principle components estimation was selected as the extraction method for factor analysis, and varimax rotation was applied. Out of five specified factors which explained 42.37% of overall variance, we were able to reproduce three subscales; emotional,

Note: Principal components analysis, showing all varimax-rotated loadings ≥ 0.30.

conduct and pro-social to a reasonable extent. Percentage of total variance accounted for by these three factors were 10.80, 10.44 and 9.37 respectively. However, we were unable to reproduce hyperactivity and peer problem subscale.

(Table 5) Internal consistencies were also computed for SDQ composite score and subscales. Cronbach’s alpha for SDQ composite score was 0.71 indicating acceptable reliability

To the best of our knowledge, this is the first study in Pakistan that has been conducted to estimate prevalence of psychiatric disorders among hearing-impaired children and adolescents.

In our study, parents rated 18%, whereas teachers rated about 33% children as abnormal. In the two other studies conducted in Pakistan, prevalence of behavioral problems rated by parents in mainstream schools and orphanages respectively in Karachi was found to be about 33% [4] [5]. However, in our study parents-rated prevalence was only 18%. In one study, a thorough review of literature from different countries was done to determine the association of hearing-impairment and psychiatric disorders in children and adolescents [19] ; it suggested that the prevalence of psychiatric disorders among hearing-impaired children varies from 15% - 60%. Moreover, the latter study suggested that the children with impaired hearing as well as children with normal hearing experience the same range of psychiatric disorders if hearing-impaired children do not have autism. This indicates that autism exacerbates psychiatric problems among children with impaired hearing.

Most of the studies reported 10% - 20% prevalence of behavioral problems among general population of normal children [20] [21]. All these studies were different in terms of study tools, study design and source of sample (samples were drawn from community, schools, institutions or primary care setting) that might contribute to differences in prevalence estimates. Our sample was drawn from special education schools and we did not have comparable data because no study has been conducted in Pakistan. However, our study findings were consistent with the reported literature regarding behavioral problems.

Furthermore, a study was conducted in Finland regarding hearing-impaired school-age children, and it also indicated no remarkable difference with regards

to psychiatric disorders between deaf and hearing children. According to the latter study, prevalence among deaf children was 18.7% whereas it was 15.8% in hearing children [22]. This prevalence rate is comparable to parent-rated prevalence in our study; in our study, all the hearing mothers and fathers were expert in sign language. Literature suggests that attitudes towards deaf children and effective communication within the family plays a significant role towards mental health of hearing-impaired children; especially relation of effective communication and low prevalence of psychiatric problems has been seen [22] [23]. Our study also supports this finding because in our study all parents were proficient in sign language. Our prevalence on SDQ composite score rating is comparable with that of a study conducted in Germany among hearing-impaired children [24] ; they also used SDQ although their cut off scores for SDQ were same as those of Goodman (normal, borderline, and abnormal) [13]. For SDQ subscales, only parent rated prevalence of emotional problems in our study is comparable with that of the German study (in our study, this prevalence is 12.9%, whereas in the German study mothers rated 15% and fathers rated 11% children as abnormal on Emotional problems).

In our study as well, parents and teachers showed poor agreement not only on composite score but on subscales as well. Although we found highly significant agreement on conduct problem scale and marginally significant agreement for composite scale, but measure of agreement (kappa statistics) showed a poor/marginal agreement that suggests lack of concordance between two informants for presence of symptoms in the same subject [25].

Our analysis indicated that risk of having psychiatric disorders is higher among children who are poor performer in class. As performance decreases, children are at higher risk of having psychiatric disorders.

Although child’s gender is associated with psychiatric problems of children, in our study it was not significant both in the univariate and multivariable analysis. Literature suggests that hearing-impaired boys are more prone to socio-emotional problems than girls especially on conduct scale e.g. aggression etc.) [26].

In addition to child’s characteristics, there are parental risk factors that can have detrimental effects on mental health of hearing-impaired children. In this study, parents’ education is significantly associated with children’s psychiatric disorders. Mother’s lack of education shows protective effect that is children of mothers with less education have lesser psychiatric problems. On the contrary, lesser degree of father’s education is putting children at higher risk of psychiatric problems. Literature suggests that children belonging to a family with low Socio-Economic Status (SES) tend to have their parents more stressed; that stress can lead to harsh and abusive parenting which is a risk factor for children’s socio-emotional problems [27].

Parental anxiety and depression has a significant role in development of children. In this study we found a highly significant association between children’s psychiatric problems and the responding parents’ depression status. In this study, we recorded depression status of the responding parent, and found that 37.5% parents were depressed; number of depressed mothers is more than that of depressed fathers. Literature suggests that maternal depression and anxiety is associated with children’s behavior problems [28]. In combination with other risk factors, maternal depression and anxiety hinders child’s early development especially in low income countries [28].

We used multi-informant rating (parents & teachers) for SDQ. We performed factor analysis and internal consistencies of overall SDQ and subscales as it has not been validated in Pakistan for hearing-impaired children. We controlled biases by giving extensive training to data collectors, especially by providing training in sign language by an expert of sign language and by conducting mock interviews in sign language in presence of that expert. Response rate was high (91%); due to the high response rate there should not be any serious limitation with regards to the selection bias.

However, there were few limitations in our study. We used cross-sectional study design, and this design in itself has limitations. We cannot establish temporality and there can be recall limitations in measurement of some variables such as child’s age at diagnosis of hearing-impairment. We did not interview only the mothers given the fact that they are closer to their children; instead, we interviewed either parent whoever was available. We used only screening tool, and did not verify children’s psychiatric problems against a diagnostic tool. We used parent version of SDQ for teachers as well because teacher version SDQ has not been validated in Urdu. AKUADS does not provide separate cut offs for anxiety and depression; therefore, we could not assess association of parental anxiety and depression separately for children’s psychiatric problems. SDQ has not been validated among hearing-impaired children in Pakistan. As our study is special school-based, its generalizability is also limited to special education institutions only. According to our knowledge, there were about seven special education schools in Karachi. However, we were unable to include all the schools either due to logistic/safety problems or permission issues from the schools management.

This study is important from the public health perspective. Since the prevalence of behavioral problems among hearing-impaired children in the special education schools was estimated to be considerable, school-based behavioral intervention programs for hearing-impaired children should be made part of their curriculum. In addition, teachers of special education schools should be provided special training and refresher programs for behavioral interventions. Poor class performance of hearing-impaired children is a strong indicator of psychiatric problems; therefore, hearing-impaired children with poor to fair class performance should be screened regularly. Parents should be screened regularly for anxiety and depression and intervention provided if found positive.

Informed consent was taken from parents and an assent form was signed by the child in accordance with the Declaration of Helsinki. Approval for this study was taken from the Ethics Review Committee of Aga Khan University and prior permission was also taken from community leaders or representatives of the study area.

None.

None for any author.

Nazar, A., Mahmud, S., Jamali, T., Khuwaja, A. and Asad, N. (2019) Screening of Psychiatric Disorders among Hearing-Impaired Children and Adolescents Aged 4 - 16 Years Attending Special Education Institutions in Karachi. Open Journal of Epidemiology, 9, 129-143. https://doi.org/10.4236/ojepi.2019.92012