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Behavior Problems in Physically Ill Children in Rwanda

Rukabyarwema, Jean Paul MD*; McCall, Natalie MD; Ngambe, Tharcisse MD*; Kanyembari, Xavier Butoto MD; Needlman, Robert MD§

Journal of Developmental & Behavioral Pediatrics: August 02, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/DBP.0000000000000698
Original Article: PDF Only

Objectives: Childhood behavior problems are underidentified in low- and middle-income countries. This study sought to systematically screen for behavior problems among children receiving medical care in Rwanda and investigate factors associated with behavior problems in this cohort.

Methods: The Pediatric Symptom Checklist (PSC) was translated into Kinyarwanda, following best practices. Children aged 5.9 to 16 years admitted to the inpatient ward of a referral hospital or seen in the outpatient department (OPD) were screened using the PSC. All PSC-positive children and every third PSC-negative child were referred for definitive assessment by a child mental health specialist.

Results: Among 300 eligible children, 235 were recruited; none refused. PSC scores were positive in 74 of 234 cases (32%, 95% confidence interval 26%–38%); a total of 28 of 74 (40%) PSC-positive children completed mental health assessments. Of these, 16 (57% of those assessed, and 7% of the 235 who were screened) required treatment or further assessment; none of the PSC-negative children did. Screening sensitivity was 100%, and specificity was 71%, with favorable receiver operating characteristics curve and internal consistency. In a multivariate analysis, higher PSC scores were associated with OPD care, central nervous system trauma or infection, and indices of malnutrition and with the use of traditional, complementary, and alternative medicine (TCAM).

Conclusion: Behavior problems are common among Rwanda children seen in a referral hospital, particularly in the OPD, and are associated with use of TCAM. The Kinyarwanda PSC showed favorable screening characteristics and resulted in some 7% of children accessing needed mental health care.

*Department of Pediatrics, University of Rwanda School of Medicine, Kigali, Rwanda;

Department of Pediatrics, Yale University, New Haven, CT;

Department of Psychiatry, University of Rwanda School of Medicine, Kigali, Rwanda;

§Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH.

Address for reprints: Robert Needlman, MD, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109; e-mail:

Disclosure: The authors declare no conflict of interest.

Received November 14, 2018

Accepted April 17, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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