In the present study, boys represented 75.7% of the study population. This is mainly due to the diagnostic preponderance of ADHD, disruptive behaviors, and developmental disorders in a sample of 83.1% primary school aged children given that these disorders are more common among boys [10, 11], and that boys tend to be referred more often [12]. Almost one-third of the sample received polypharmacy, an alarming phenomenon that is present in both developed [13], and developing countries [14]. Comer et al. analyzed data of 3466 child and adolescent visits to office-based physicians in the USA and reported an increase in the percentage of polypharmacy from 14.3 (1996-1999) to 32.2% (2004-2007) [15].
The most common pharmacological combination in our sample was antipsychotics plus ADHD medications, which also seems to be the case in other settings [15, 16]. Although the rationale behind the clinical decisions concerning psychotropic co-prescription was not routinely documented, the main reasons for polypharmacy could be the state of emergency represented by disorders accompanied with aggressiveness and externalizing behavioral symptoms, as well as a tendency toward symptom-based management [17]. This practice may not necessarily be improper as it is useful in some clinical situations, such as the treatment of adverse effect of another agent, co-existing conditions (e.g., seizure and psychosis), and immediate relief of symptoms before having symptomatic improvements resulting from the main medication [18].
The agreement between the observed intervention pattern in the sample and the Maudsley guidelines was extremely low, even among the psychiatrists. Bazzano and colleagues examined data from the 2004 National Ambulatory Medical Care Surveys and reported that 62% of pediatric outpatient visits involved off-label prescriptions and deviations from prescribing guidelines across all medication categories, with the off-label prescribing being more frequent for younger children [19].
However, the main deviation of the observed intervention pattern in this sample and the Maudsley guidelines was the absence of psychotherapeutic intervention, although these interventions are considered a first-line treatment for conditions such as mild cases of ADHD, social phobia, mild to moderate depression, and generalized anxiety disorder [20]. This phenomenon could be attributed to several factors such as the high costs of psychotherapy in private settings and the lack of such resources in many communities, especially in developing countries, that renders pharmacotherapy a more readily available option for many [20]. More specific reasons might be the paucity of psychotherapeutic training in Egypt, which lacks a clinical board of psychotherapy, as well as other cultural reasons pertaining to avoidance of intense and long involvement with mental health specialists. Finally, specific characteristic of the study design and sample could also account for this phenomenon, namely, the exclusion of unprescribed children who might be receiving psychotherapy, the number of cases that was treated by either pediatricians or neurologists who lack knowledge and experience in psychotherapy in comparisons with psychiatrists, and the distribution of diagnoses of the sample subjects (i.e., few cases with anxiety and depression, while the fact that were referred for their neurodevelopmental symptoms to a tertiary center probably signifies that their cases were more severe and complicated).
Off-label use of medications and higher-than-indicated prescribed doses were also often causes of discrepancy from the guidelines. This phenomenon is generally more common among pediatric population [21], with antipsychotics, for instance, being prescribed outside their approved indications in 54.2% of their use, both in specialized and non-specialized childcare settings [22]. This study reveals significant weaknesses in the management of children with mental health problem in primary care settings in Egypt. Although some common setbacks pertaining in caring for this population worldwide, our study revealed a big gap in the primary or combined use of psychotherapeutic interventions and the safe and appropriate use of medications according to the international literature. These warrant to be readily dealt by health providers, both through expanding the relevant training and informing all primary health care workers about evidence-based practices.
Limitations
The lack of available detailed file data and the use mainly of the history provided by the parents make our results more prone to recall bias. For the same reason, we had to exclude unprescribed patients which, on one hand prevented us to assess their management and on the other may have compromised the generalizability of our conclusions, given the fact that the cases we did assess could have been the more severe ones, thus needing a medication.
Furthermore, the cases presented to our tertiary center after a prior consultation elsewhere, could have been a non-representative sample consisting of the more complicated resistant cases, which in its turn could explain the non-adherence to classical guidelines. The late seems not to be the case, for the following reasons: (a) the referral system in Egypt is not following the strict protocols seen in developed countries and a case to be seen does not need to have a referral from primary or secondary health care providers. Actually, cases can choose to be seen in a tertiary clinic as a first visit; (b) 83.5% of our sample were definitely not seen as resistant or complicated cases. Another limitation is that our data could be relatively old as the study was conducted from May 2015-May 2016, which is more than 5 years ago, as data could be somewhat changed now.
