To our knowledge, this is the first study conducted to determine the prevalence of behavioral problems among school going children and adolescents in rural Uganda. Data from multiple measures demonstrate the existence of behavioral problems among school children. Specifically, the 9.61 and 5.59% estimated prevalence of ODD as measured by Iowa Connors scale and DBD scale respectively were high. Similarly, approximately 2 % of the sample evidenced symptoms of CD measured by the DBD scale. Moreover, 2.67% screened positive on ADHD using the Iowa Connors scale. Several studies conducted in other sub-Saharan countries have reported prevalence rates that range between 1 to 20% . For instance, in South Africa, Bakare reported that the prevalence of behavioral problems among school going children, particularly ADHD, varies between 5.4 to 8.7% , while Chinawa et al. reported a prevalence rate of 3% for ADHD among school going children seeking treatment at health facilities in Nigeria . Our prevalence rates for DBDs as measured by DBD scale (6.2%) and Iowa Connors scale (11%) are not different. Not many studies have looked at DBDs like our study. Most studies conducted in Uganda have focused on ADHD and been carried out in health facilities. For example, Wamulugwa et al. reported a prevalence rate of 11% and Mpango et al. reported a prevalence rate of 6% for ADHD among children with psychiatric diagnoses and HIV-positive adolescents respectively in Uganda [15, 16]. Our study reported lower rates of ADHD (2.67%), which could be most likely due to the difference in study population. Populations used in these studies were clinical samples, unlike our community-based sample.
Similarly, another study conducted in Ethiopia among a community sample found the ADHD prevalence to be at 1.5%, which is consistent with our findings (2.67%) . Wamulugwa and colleagues found prevalence rates of 11% for ADHD and 8.5% for CD among children with neurological and psychiatric disorders , yet our study was done in rural public schools among children who had no prior neurological or psychiatric diagnoses. On the other hand, prevalence rates of ADHD in studies conducted in the United States (US) among national samples [24, 25] are also in range with prevalence rates reported in clinical samples in sub-Saharan Africa. For instance, among a sample of children aged 4–17 years in the US, the study found prevalence rate of 11% for ADHD , consistent with the results reported by Wamulugwa and colleagues among a clinical sample . one should note that the overdiagnosis of ADHD has been pointed out as a concern in the United States . Hence, the variation observed could be largely attributed to the different age groups included and/or the use of clinical versus community samples. Thus, our prevalence rate is consistent with other study findings with community samples in sub-Saharan Africa and may be a true reflection of the prevalence of behavioral problems among school children.
In addition, 25% of children were described by their caregivers to experience impairment in at least four out of six domains of the Impairment scale. As a result, the prevalence rates reported in this study for DBDs could potentially impact school performance, social functioning as well as peer interaction among children and requires immediate public health interventions. The high reported rates of impairment associated with behavioral problems could be attributed to abject poverty, violence and parental mortality and HIV/AIDS [16, 22].
Our study contributes to scientific knowledge by providing epidemiological data on the prevalence of DBDs among school-going children in Uganda. Our results indicate a high prevalence of DBDs among children, which are associated with negative health and educational outcomes including delinquency, violence, drug use, poor academic performance, and anti-social personality if left untreated. Given the negative developmental outcomes associated with DBDs, particularly on academic performance and social functioning [26, 27], it is essential to screen and identify DBDs at their onset and provide necessary mental healthcare. Assessment and diagnosis are necessary in early identification of the disorders and in determining how to target and tailor interventions for specific disorders. Additionally, it is paramount to establish and develop robust context specific surveillance systems that facilitate screening, treatment and monitoring of children with DBDs.
Secondly, our results have vital implications for programming and policy, especially in sub-Saharan Africa where in most cases, there is severe scarcity of mental health professionals, evidence based interventions as well as mental health policy guidelines. The findings underscore the need to provide child and adolescent mental health training to school teachers to equip them with skills necessary for screening and early identification of DBDs and ADHD. These can include short-term certificates, as well as advanced degree programs tailored for school professionals with a potential to expand child and adolescent mental health care workforce. This calls for training not only in identification but also training in the delivery of brief, low-cost and effective evidence-based interventions developed and−/or adapted to the Uganda/sub-Saharan Africa context. In addition, there is need to support and provide ongoing training and supervision to community health workers/lay workers that already exist in the health and education systems. Previous research has underscored the positive mental health and psychosocial outcomes from interventions delivered by lay workers with little or no prior mental health training . In the Uganda context, these would include teachers, community health workers, village health teams as well as parent-teacher association members that work directly with students and within communities. Further, there is a need to build and strengthen the mental health policy framework in sub-Saharan Africa which explicitly addresses strengthening mental health care needs in non-stigmatizing settings including families, schools and primary health care clinics.
The findings presented in this study require careful interpretation in light of the following limitations. First, although the study was conducted in many schools, we cannot conclude that rates of DBDs evidenced in the sample are nationally representative of school going children. Moreover, study findings are based on children in rural Uganda, enrolled in grades 2 through 7, between the ages of 8–13- years-old as specified in our inclusion criteria. As a result, findings are not necessarily generalizable to families with older or younger children in both rural and urban areas. Certainly, the large sample of children involved in this study provides reliable estimates of the prevalence of DBDs among rural school children in Uganda.
Secondly, this study exclusively relied on parent reports of behavior for measures of DBDs. Understandably, having multiple reporters (e.g., parents, teachers, non-teaching staff and children) would have provided additional information on the symptoms exhibited by children. This is a notable limitation of the current study. However, other studies have relied on caregiver reports using similar measures which increase confidence in the validity of the prevalence rates found in this study [15, 29, 30].