SF Hung

Behavioural problems are quite common in the young population. Indeed, it is one of the commonest presentation to the practicing Paediatricians. Parents are often worried about different problem behaviours as their child grows. In the early years, they worried about feeding, sleeping, sphincter control, then about aggression, overactivity, fears, peer relationship, balance between dependence and independence, and in Hong Kong, a particular concern on their school performance once they started school. Most of these problems are transient and self remitting and are amenable to common sense advice. More recently, the phenomenon of behavioural inhibition in infants are noted to predict emotional problems later. However, it is those that are severe, persistent, with multiple problems, cause distress in the child and/or their parents, and impairing their development which merit special attention. These are referred to as behaviour disorders. They tend not to be transient nor self-remitting and predict problems in the future. These disorders are often associated with a number of risk and protective factors such as prematurity, temperament, infant-caregiver attachments, psychopathology in parents, parents' marital quality and interactions, etc. which could either aggravate or ameliorate the problem.

There have been relatively few epidemiological studies of behaviour disorders in children in Hong Kong. To this author's knowledge, there has not been a good epidemiological study on infants in Hong Kong. For Preschoolers, Luk et. al.² reported a two stage epidemiological study on a representative sample of 855 Hong Kong Chinese children aged 36-48 months, using parent and teacher questionnaire and interview as stage 1 screening and a semistructured clinical interview of teachers, parents and child as stage 2 assessment. They found that the prevalence of behaviour disorders was mild 18.0%, moderate 4.5% and severe 0.7%. The result is fairly similar to those reported by Richman et al (1975) in U.K. Considering the likely differences in child rearing practices in the two culture, the similarity is interesting. Leung et al.¹ in another two stage epidemiological study of hyperactivity in Hong Kong, screened a representative sample of 3069 primary one boys followed by semistructured clinical interview. They found that the prevalence of hyperkinetic disorder as defined by ICD-10 is around 0.78%. The prevalence is lower than the finding in United Kingdom (1.7%). It is noteworthy that the two sites share the same methodology which makes the comparison particularly meaningful. They discussed that both biological and cultural explanation apply. The Chinese may be constitutionally less vulnerable to hyperactivity. Culturally, the Chinese child rearing practice, school environment, and social expectation all encourage discipline, conformity and inhibition of impulses. They also noticed that using Questionnaire alone, our teacher's rating yielded a higher rate of hyperactivity. The phenomenon probably reflected a lower tolerance for disruptive behaviours amongst teachers. They also concluded that a disorder of hyperactivity do exist in the Chinese, displaying the same kinds of symptomatology and external correlates as in the West. Wong & Lau³ reported a two stage study of 718 Chinese primary two and four pupils in a school and found the total prevalence of definite psychiatric case to be 16.3%. They also reported that boys have more problems than girls. Leung et al (personal communication), in a recent study conducted to renorm the Child Behaviour Checklist(CBCL), Teacher Report Form(TRF), and Youth Self-report Form(YSR) in a representative sample of primary and secondary students had found that the local norm is very similar to their American counterparts. Any differences found are small. The School Health Services of Hong Kong (personal communication) had used the same instrument in screening in the student population and had similar finding. Judging from this finding, we may again infer that the youth in Hong Kong are more similar than different in their problem behaviours when compared with other countries. However, this study uses self-administered questionnaire only and may be less accurate than those quoted above.

More recently, there is a worrying trend of a possible increase of suicide amongst the young. Ho et al ⁴ reported that the overall pattern and associated risk factors (except methods of suicide) is quite similar to the West. The suicide rate was lower in Hong Kong and so are the associated risk factors such as drug abuse. In a recent study (Hung et al.⁵) of 10 secondary schools, the estimated lifetime prevalence of suicidal idea, communication, plan, and act are 23%, 9%, 7% and 4.5% respectively. They are comparable to those reported in the West. It appears that the pattern may be changing towards an increase of risk factors (drug use, family breakdown, unemployment, etc) and we may be facing an increase in suicide and suicidal behaviours in the young.

With the limited available data, it could be postulated that the behavioural problems in the young share more commonalties than differences when compared to other countries. There are nevertheless some minor variation which requires further studies.

In Hong Kong, over 95% on newborn are screened in Maternal and Child Health Centers. Other than vaccination, they are also screened for behavioural deviance and delay. Common, transient problems are dealt with there. For those with more severe problems, they are referred to Child Assessment Center. In 1997, 2367 cases were assessed. Most of them suffered from developmental delay of one form or others, 4.2% suffered from attentiondeficit disorder (Personal communication). Paediatricians also handle some of the common problems. Some of them are referred to the Child Psychiatrists. In the public sector, there are now four teams of Child Psychiatric Services, two in University Hospitals and two in the Hospital Authority. In Yaumatei Child Psychiatric Center, one amongst the four teams, they serve around 850 new cases each year, with an age span of 2 years to 19 years of age.

Behavioural problems are common in children and adolescents. In Hong Kong, we still lack good epidemiological data on the size of the problems. In broad terms, from the available data, we can infer that the pattern of behavioural problems are quite similar to the West. There are some local variation which are of particular interest. It may help us to understand the importance of biological factors (nature), whether the Chinese may have a different genetic make up. Alternatively, environmental factors of different culture (nurture), that different child rearing practices, different schooling, different social expectation , etc could have an important impact on child development. More research in the area is needed.

References

1. Leung PWL, Luk SL, Ho TP, Taylor E, Lieh-Mak F, Bacon-Shone J. The diagnosis and Prevalence of Hyperactivity in Chinese Schoolboys. Br J Psychaitry 1996;168: 486-96.

2. Luk SL, Leung PWL, Bacon-Shone J, et al. Behaviour Disorder in Pre-school Children in Hong Kong : A Two-stage Epidemiological Study. Br J Psychiatry 1991; 158: 213-21.

3. Wong CK, Lau JTF. Psychiatric Morbidity in a Chinese Primary School in Hong Kong. Aust N Z Psychiatry 1992; 26: 459-66.

4. Ho TP, Hung SF, Chung SY, Lee CC, Chung KF. Characteristics of Youth Suicide in Hong Kong. Soc Psychiatry Psychiatr Epidemiol 1995; 30:107-12.

5. Hung SF, Ho TP, Leung PWH, Lee CC, Tang CP. Characteristics and Psychopathology among Peers of Suicide Attempters and Completers Final Research submitted to Health Services Research Committee. Hospital Authority, Hong Kong in 1998.