INTRODUCTION
Numerous mental health disorders in childhood and adolescence typically begin during the early-to-middle years. Certain disorders emerge during a child’s developmental phases. These conditions lead to challenges across various areas of development, including the personal, social, and academic domains. Consequently, these challenges can result in deficiencies in learning abilities, intelligence, and language skills, which may delay the achie-vement of important developmental milestones [1]. The phrase “neurodevelopmental disorders” (NDDs) refers to a wide range of disabilities that are associated with some interruption in the development of the brain [2].
Mental health issues remain a significant priority in the realm of global public health [3]. In 2014, psychiatric disorders represented about 13% of the worldwide health burden, with depression identified as a major contributing factor [4]. Globally, 8.8% of the population of children and adolescents have been diagnosed with a variety of mental illnesses, with several disability-adjusted life years (DALYs) of 21.5 million in 2019 [5]. There exists a significant disparity between the mental health needs of these young individuals and the resources available to address them, particularly in many Asian nations [6].
The overall prevalence of mental disorders in this demographic was found to be 15.5%. The most commonly reported mental health symptoms included phobic anxiety (17.3%), interpersonal sensitivity (14.7%), and obsessive- compulsive symptoms (14.5%) [7]. Additionally, the pre-valence of post-traumatic stress disorder (PTSD) was recorded at 25.2% among Syrian refugees residing in Domiz Camp, located in Duhok City [8]. A study in Duhok City examined the mental health and school performance of street-working children. It involved 120 boys from the streets and a comparable group from primary schools, revealing that street-working children were five times more likely to be depressed and four times more likely to experience anxiety [9].
To the best of our knowledge, this is the inaugural study focused on examining the demographic and clinical traits of a group of children experiencing emotional and behavioral issues who are seeking psychiatric services in Duhok city, located in the Kurdistan Region of Iraq. The importance of this study lies in its potential to fill a significant gap in understanding childhood mental health in the Middle East, specifically in the Kurdistan Region. By providing a comprehensive analysis of the demographic, clinical, and familial profiles of children with mental health disorders, the study aims to inform local healthcare practices and policymaking. It emphasizes the early onset of psychiatric disorders, highlighting the need for timely interventions that are culturally relevant. The findings offer valuable insights into risk factors associated with mental health issues, guiding future research and intervention strategies, ultimately promoting awareness and improving access to care for the children and adolescents affected.
METHODS
Research design
This retrospective cross-sectional study investigated the mental health profiles of children and adolescents who visited or were referred to the Child and Adolescent Mental Health Center in Duhok City in the Kurdistan Region of Iraq. To achieve this objective, the medical records of clients diagnosed and treated at the center were systematically screened, and relevant characteristics were extracted from these medical records.
Population, setting, and sampling
The study population consisted of clients from the Duhok Child and Adolescent Mental Health Center, which serves as the sole facility for diagnosing and treating mental health disorders in children and adolescents within the Duhok Governorate. The individuals selected for this study attended the facility between 2015 and 2024.
The Duhok Child and Adolescent Mental Health Center serves as the primary governmental psychiatric faci-lity in the Duhok province, offering a range of services including diagnosis, treatment, education, training, and routine follow-up for patients from Duhok and surrounding areas, as well as displaced immigrants seeking refuge from the Islamic State in Iraq and Syria (ISIS) crisis. Established in 2005, the center has accumulated nearly 33,000 medical records, providing a substantial time frame for analyzing data spanning over a decade. The center’s inclusion criteria encompass all patients aged 3 to 18 years who visit during business hours. The number of cases received fluctuates according to the development of various situations and crises, typically ranging from 12 to 15 cases daily. Families have the option to bring their children for follow-up appointments each month. The center offers medical and therapeutic services tailored to the specific needs of the children, including art therapy, cognitive behavioral therapy (CBT), and other services. Court cases are processed each Monday, parti-cularly for children whose parents are separated, incarcerated, or facing other challenges such as drug abuse. However, patients with autism spectrum disorder (ASD) do not receive treatment at this center; instead, they are referred to a specialized ASD center in Duhok City or may seek services at private autism centers. The process of receiving cases involves referrals from hospitals, schools, camps, or direct visits.
Due to the center’s high volume of patients, including all of the center’s clients in this study was impractical. Therefore, a systematic sampling technique was employed to select a representative proportion of the population. Specifically, one case was included from every ten medical records stored in the Archive Unit of the center. In instances where the tenth case exhibited excessive missing information or was not applicable for an unknown reason, the eleventh case was included instead. Ultimately, 852 cases were selected for analysis beginning from case number 8,600 in the records available from 1st January 2015 to 15th July 2024.
Study measures
The study measures incorporated various socio- demographic data, including gender, birth date, location, source of referral, level of education level, years failed in school, family type, number of family members, and parental details such as age, education, and occupation. A developmental history assessed psychosocial problems, exposure to medication, maternal smoking or alcohol use, and perinatal and postnatal history, along with developmental milestones and social relationships.
Behavioral assessments focused on orientation, the nature of the relationship with the interviewer, mood and affect, language proficiency, thought processes, phy-sical functioning, sleep patterns, cognition, amnesia, suicidal ideation, and insight and judgment. The diagnosis and treatment section encompassed the final diagnosis, pharmacotherapy, psychotherapy, family therapy, support networks, external referrals, medical follow-up, and psychiatric follow-up. This comprehensive approach consolidates the data collected into a cohesive format for enhanced analysis and understanding of mental health assessments.
Ethical considerations
Ethical and administrative approval for this study was secured from the Duhok General Directorate of Health and the Child and Adolescent Mental Health Center in Duhok City. The study protocol was registered on March 27, 2024, under reference number 27032024-2-12. To uphold client confidentiality, all identifiable information was safeguarded and excluded from the data collection files. This commitment to ethical standards ensures the pri-vacy and rights of all participants involved in the study.
Statistical analyses
The general and medical characteristics of the patients with mental disorders were presented in mean and standard deviation for continuous variables, and number and percentage for nominal variables. The prevalence of a history of psychiatric disorders, developmental history, and final diagnosis were determined in terms of number and percentage. The comparisons of the prevalence of mental disorders, NDD, and anxiety disorders between patients with mental disorders and normal patients were examined with the Pearson χ2 test. The significant level of difference was identified at p < 0.05. The statistical calculations were performed using JMP®, Version 18.0. SAS Institute Inc., Cary, NC, 1989-2023.
RESULTS
The study found that the mean value of the age of the patients was 10.97 (standard deviation; SD: 4.31 years), with them being aged between 2 and 22 years. Most of the patients were at school age (58.21%), followed by teenagers (23.72%) and young adults (9.29%). The patients who were included in the study were in preschool (6.47%) and toddlers (2.32%), from the following regions; Duhok (447, 52.47%), Semel (112, 13.15%), Zakho (78, 9.16%), refugee camps (75, 8.80%), Shekhan (46, 5.40%), Amedi (37, 4.34%), Akre (27, 3.17%), Bardarash (16, 1.88%), Zummar (5, 0.59%), Barzan (3, 0.35%), Shingal (3, 0.35%), Erbil (2, 0.24%), and Baadre (1, 0.12%). The patients had been referred directly both (52.22%) and indirectly (47.78%). They were referred by different departments or persons, including doctors (77.04%), the local health committee (10.58%), the school (8.53%), the governmental or non-governmental organizations (3.37%), UNICEF (0.36%), and the cases of court (0.12%). The study found that 23.19% of the children had failed at school. The patients were mostly from nuclear families (99.76%) and had 6-10 family members, followed by 3-5 (40.33%). Most of the parents were between 30 and 49 years old and had different occupations (Table 1). The most occupations of the fathers were workers (working as worker in private sector; 52.28%), followed by Peshamarga/military job (17.09%), and employees (governmental employees: 12.25%); among the mothers they were housewife (87.94%), followed by teacher (6.10%), and employee (governmental employees; 4.82%; not shown in tables).
Table 1
Socio-demographic and medical characteristics of the children with mental disorders studied (N = 852)
The study found that the most common psychiatric disorders of their parents of the children were those of psychological development (6.93%), followed by mental retardation (5.75%), and behavioral and emotional disorders with onset usually occurring in childhood and adolescence (2.70%); 80.99% of the children had no family history of psychiatric disorders. From their medical records, it was found that 2.48% had received medication or been exposed to X-rays; (0.36%) of the mothers had smoked or consumed alcohol. The delivery types in patients were normal vaginal delivery (NVD) (74.19%) followed by Cesarean Section (CS) (22.58%) and difficult labor (3.23%). We found that 15.99%, 6.14%, and 9.22% had delayed crying, seizure, and jaundice, respectively. In addition, the study found that 2.72%, 3.18%, 4.59%, and 22.62% had delayed baby creeping, head control, sitting, and walking, respectively. We found that 44.88% had delayed talking, 4.25% had delayed dentition and 10.15% were isolated socially. Also, 6.96% and 5.22% had no friends or hobbies, respectively (Table 2).
Table 2
Family history of psychiatric disorders and developmental history in the children with mental disorders studied (N = 852)
The study found that 50.3% of the young people had difficulties with language, including aphasia (9.61%), stuttering (6.40%), muteness (0.74%), paralogia (0.49%), and delayed development of language (0.25%). Some of the patients had issues with their thinking, including excessive thinking (6.5%), followed by obsession (4.07%), and some were hyperactive (2.11%) or hypoactive (27.70%). In terms of appetite, some of the patients were hypoactive (9.16%) or hyperactive (0.5%). Some of those included in the study experienced abnormal sleeping (7.20%), including insomnia, night walking, night terror, nightmares, and hypersomnia; and some had amnesia (9.09%) and suicidal ideas (n = 4; Table 3).
Table 3
Application and behaviors of the patients
Most of the patients were receiving pharmacological treatment (96.90%), and multiple types of psychotherapy were being offered to a significant minority (29.68%). The latter included cognitive therapy, play therapy, behavioral therapy, CBT, and environmental therapy. Most received family therapy (85.92%) as well. The study found that the moss common psychiatric disorders among the children were disorders of psychological development (69.25%) followed by neurotic, stress-related and somatoform disorders (11.27%) and organic, including symptomatic, mental disorders (the organic disorders included symptomatic and mental disorders; 5.16%); 8.57% had no psychiatric disorder (Table 4).
Table 4
Diagnosis and intervention in the patients studied
It was found that preschool children were more likely to have normal conditions or no mental disorders at screening time (20.51%) than other age groups (p = 0.0334). In addition, the patients with a family history were more likely to have mental (95.68% vs. 90.43%; p = 0.0319) and NDD (94.62% vs. 87.57%; p = 0.0216). The patients who were referred indirectly were more likely to be diagnosed with NDD (p = 0.0404; Table 5).
Table 5
Prevalence of mental discovers, neurodevelopmental disorders, and anxiety disorders between patients with mental disorders and normal patients (N = 852)
DISCUSSION
Preschool-aged children were more likely to exhibit neurodevelopmental conditions compared to those in older age groups. Additionally, children with a positive family history of psychiatric disorders were more prone to being diagnosed with NDD.
The research focused on understanding the background and prevalence of common psychiatric disorders among children and adolescents with a familial history of mental health conditions. The findings highlighted that NDDs are the most frequently identified disorders in this population. A major challenge in addressing these issues is the limited availability of psychiatrists for children and adolescents and the overall scarcity of mental health services in the country, which hinders effective diagnosis and treatment. Furthermore, the social stigma associated with families affected by psychiatric disorders, along with varying socioeconomic and educational levels, exacerbates the issue. Social and economic inequality can create disparities in people’s mental health. Individuals who have limited access to economic resources or who face particular social pressures may be more susceptible to developing mental health problems. Therefore, research on the influence of socioeconomic factors on people’s mental health is becoming increasingly urgent [10].
The exposure of children to the internet and smartphones, alongside the rise in bullying, contributes to the increasing prevalence of mental health disorders within our community. A study done by Ismail [11] in Duhok City, among children under 5 years, showed that older children are more likely to use mobile devices. Children who have their own mobile devices are more likely to use them [11]. A meta-analysis highlights that prolonged screen time can negatively impact the development of young children’s language and social skills, which is attributed to the challenges they face in learning from screen interactions compared to real-life engagements [12].
Global epidemiological data reveal that up to 20% of children and adolescents worldwide suffer from debi-litating mental illnesses, with suicide ranking as the third leading cause of death in this age group. Additionally, around 50% of adult mental health conditions begin during adolescence [13]. The burden of mental disorders has risen significantly over the years, moving from the 13th leading cause of DALYs in 1990 to the seventh by 2019, underscoring their widespread impact across nations. The highest DALY rates are observed in countries such as the United States, Australia, New Zealand, Brazil, and parts of Western Europe, sub-Saharan Africa, North Africa, and the Middle East. In contrast, lower rates are found in Southeast Asia (e.g., Vietnam, Myanmar, Indonesia), East Asia, affluent Asia-Pacific regions, and Central Asia. While individual country rates vary, they gene-rally fall within overlapping uncertainty ranges compared to the global average [14].
In Iraq and neighboring regions, prevalence rates are notably higher, ranging from 10% to 36% significantly exceeding figures from developed nations. These conditions are a leading cause of disability among youth worldwide [15]. Research in Erbil, Kurdistan Region of Iraq, found that 43% of child and adolescent psychiatric outpatients were diagnosed with NDDs, 26.6% with intellectual disabilities and behavioral/emotional comorbidities, and 30.4% with other mental or behavioral conditions. This high level of prevalence may be linked to the mental health impacts of war, displacement, and trauma, which leave many children facing uncertain futures [16]. In Iraq, attention deficit hyperactivity disorder (ADHD) among school-aged children (6-10 years) is reported at 10.5% by teachers and 5.9% by parents [17]. Similarly, in Iran, ADHD prevalence is 8.5% among those under 18, with 4.6% identified through screening in primary schools [18].
Research often focuses on children aged 6 to 12, as this is when they begin school and face new challenges, prompting parents to notice differences and seek help [19, 20]. Stressors during this period can negatively impact performance and increase the risk of school dropout [21].
NDDs are the most diagnosed, accounting for 69.01% of cases, with ASD, ADHD, and intellectual disabilities being the most prevalent. Emotional disorders like depression (1.06%) and anxiety (5.99%) are less frequently observed in referred youth populations to the hospitals or centers. Globally, ADHD prevalence in children and adolescents is estimated at 8%, with consistent rates across regions except for variations in Black, White, Asian American, Indians, and Middle Eastern populations. Meta-analyses in Africa, China, Spain, and global studies report the prevalence of ADHD to be 6% and 7.5% [22-25]. In the UK, the rates of Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) are 2.3% and 1.5%, respectively [26], while U.S. studies report slightly higher rates of 2.8% to 5.5% for ODD and 2.0% to 3.32% for CD [27].
Depressive and anxiety disorders remain significant global health burdens, ranking 13th and 24th in DALYs respectively. Their prevalence and associated disability weight exceed those of many other health conditions. Although schizophrenia affects a smaller population, its disability weight for acute psychosis is the highest recorded in the Global Burden of Disease (GBD) study [28]. DALY rates for mental health disorders are higher in many high-income countries and lower in parts of sub-Saharan Africa and Asia, where limited data availability increases uncertainty. Disorder-specific trends show elevated DALYs for depressive and anxiety disorders in regions with high rates of childhood sexual abuse, intimate partner violence, and conflict [29].
In Iraq, mental health challenges are exacerbated by factors such as exposure to violence, forced displacement, and ongoing instability. Decades of conflict, economic sanctions, and civil unrest have severely impacted the population, particularly children, with violence, po-verty, and the collapse of education and healthcare systems undermining well-being [17].
Notably, over 50% of families seeking help at clinics report concerns about speech delays or impairments, often fearing conditions like deafness or autism. Speech difficulties are a key early indicator of these disorders [30]. Children with speech and language impairments are often underrepresented in studies on communication disorders, despite 8% to 12% of preschool populations exhi-biting language impairments, often alongside other disabilities [31].
This study has limitations due to its retrospective design, primarily the reliance on existing hospital records, which may not always be complete or accurate. The clini-cal profile of the patients was assessed using an ad hoc questionnaire designed specifically for this study to capture data from hospital records, and it was difficult to locate all files from 2015 to 2024. Some forms were not completed and some questions were missed. Further research should integrate validated instruments by adapting existing tools to the local context or supplementing them with hospital-specific variables to improve metho-dological rigor and ensure comparability with broader research.
CONCLUSIONS
The study highlights the high prevalence of disorders of psychological development and mental retardation within families.
There is a connection to a family history of mental disorders.
A proportion of participants had a family history of psychiatric disorders, predominantly NDDs.
There is a significant link between mental health and academic performance, with many children reported to have failed in school.
Developmental delays, particularly in communication skills, were common, with many children experiencing delayed speech.
A substantial percentage of patients had received pharmacological treatment.
Some of the children were engaged in some form of psychotherapy, yielding a high recovery rate post- treatment.
Preschool children were more likely to exhibit normal conditions without a mental disorder.
Those with a positive family history faced increased risks of mental and NDDs.
There is an urgent need for early detection, intervention strategies, and effective referral pathways to better support the mental health of children and ado-lescents.
RECOMMENDATIONS
To effectively tackle mental health issues in children and adolescents it is crucial to increase access to services by recruiting more child psychiatrists and expanding school-based mental health support. Community education programs can help reduce stigma and aid families in recognizing early signs of disorders. Socioeconomic support is vital, as low income correlates with higher mental health risks; therefore, initiatives should focus on alleviating financial hardship. Regular mental health screenings in schools are essential, particularly for ages 6 to 12, utilizing validated tools for accurate assessment. Promoting healthy screen time and managing digital interactions can mitigate negative impacts, while prioritizing language development through targeted interventions is necessary. Research efforts should focus on accurate data collection, and family involvement in treatment, along with the development of crisis intervention programs, will strengthen the overall support system for affected children and their families.
