1 SUBMITTED 18 APR 22 1 REVISION REQ. 8 JUN 22; REVISION RECD. 13 JUL 22 2 ACCEPTED 3 AUG 22 3 ONLINE-FIRST: AUGUST 2022 4 DOI: https://doi.org/ 10.18295/squmj.8.2022.049 5 6 Parental Attitude towards the Prescription of Psychotropic Medications for 7 Mental Disorders in Children in a Tertiary Care University Hospital in Oman 8 Hiba Al-Harthi1, Salim Al-Huseini1, Mohammed Al-Shukaili1, Moon Fai 9 Chan2, Tamadhir Al-Mahrouqi1, Mohammed Al-Breiki3, Amira Al-Hosni4, 10 *Hassan Mirza4 11 12 1Psychiatry Residency Training Program, Oman Medical Specialty Board, Muscat, Oman; 13 Departments of 2Family Medicine & Public Health and 4Behavioural Medicine, Sultan Qaboos 14 University, Muscat, Oman; 3Saham Polyclinic, Ministry of Health, Saham, Oman. 15 *Corresponding Author’s e-mail: mirza@squ.edu.om 16 17 Abstract 18 Objectives: This study investigated parental attitudes towards psychotropic drugs for children's 19 mental disorders. Methods: A questionnaire was distributed to parents of children attending a 20 child psychiatry clinic at a tertiary hospital in Muscat, Oman. Similarly, in a small proportion, 21 other caregivers filled out the questionnaire in case the child attended with them. The 22 questionnaire comprised questions regarding parents' opinions, and attitudes about psychotropic 23 medications use. The logistic regression model was used to identify the risk factors associated 24 with parents who prefer to consult a folk healer (FH) for children with mental disorders. Results: 25 A total of 299 parents agreed to participate in the study. The majority of them (81.6%, n=244) 26 agreed that they would give their child psychotropic medications if necessary, but 25.4% of them 27 (n=76) would consult a FH before consulting a psychiatrist if their child experienced psychiatric 28 symptoms. Married parents were 14 times (OR=14.5, p=0.011) more likely to consult a FH than 29 were separated or divorced parents. Caregivers with a monthly income below 500 OMR and 30 mailto:mirza@squ.edu.om 2 between 500-1,000 OMR were two times (OR=2.5, p=0.016) and three times (OR=3.2, p<.001), 31 respectively, more likely to consult a FH than those with a monthly income of more than 1,000 32 OMR. Parents who disagreed with giving psychotropic medications to their children were three 33 times (OR=3.7, p<.001) more likely to consult a FH than were parents who agreed to give 34 psychotropic medications to their children if necessary. Conclusion: Most parents agreed to give 35 their children psychotropic medications if it were deemed necessary. However, a sizeable 36 proportion of parents and caregivers preferred to consult a FH before accessing mental health 37 services. 38 Keywords: Parents; Children; Attitudes; Psychotropic Drugs; Oman. 39 40 Advances in Knowledge 41 -As a flagship institute, the Sultan Qaboos University Hospital aims to provide all our service 42 users with the best care. 43 -Therefore, this study helped us identify the parents’ and caregivers' opinions, concerns, and 44 perceptions on the use of psychotropic medications in children. 45 46 Application to Patient Care 47 -The results of this study and its implications will help us better understand parents' and 48 caregivers’ attitudes towards using psychotropic medications in children. 49 -In addition, the feedback will help us develop parent support groups to discuss the concerns 50 further and improve our services, which translates into better concordance and compliance with 51 the formulated management plan. 52 53 Introduction 54 The number of evidence-based treatments for child psychiatry is growing.1,2 There has been a 55 dramatic rise in the use of psychiatric drugs in children over the past four decades.3-5 56 Unfortunately, studies have shown a sceptical view and stigma among parents and caregivers of 57 psychiatric patients on using psychotropic medications for their children. 6,7 Therefore, most 58 families prefer psychotherapy over drugs, even when psychopharmacological agents are deemed 59 crucial. 8,9 Previous studies suggest that parents are reluctant to commence their children on 60 psychotropic medications. This attitude is due to concerns about severe and harmful side effects, 61 3 leading to reducing or stopping the medication earlier than recommended. 10 In addition, studies 62 identified existing racial/ethnic disparities among parents agreeing to prescribe psychotropic 63 medications for their children. For example in the USA, White children are more likely to 64 receive psychotropic drugs than Black and Latino children. 11,12 However, the view of and 65 attitude toward the use of psychotropic medications in children in Oman have never been 66 explored. Therefore, understanding the cultural context and establishing relationships between 67 mental health care providers and parents may offer the best strategies for reducing the negative 68 parental perceptions relating to prescribing psychotropic medications for their children. 69 70 The current study aims to explore and understand the opinion and attitudes of Omani parents 71 towards prescribing psychotropic medications to their children with mental disorders. It is hoped 72 that child psychiatrists will alleviate parental concerns regarding psychotropic medications use in 73 their children and effectively reduce parental stigma regarding mental health. 74 75 Methods 76 Study design, settings and participants 77 This cross-sectional study was conducted at the Department of Behavioural Medicine, Sultan 78 Qaboos University Hospital (SQUH) in Oman, between December 2020 and March 2021. In this 79 study, all patients aged younger than 18 years who were attending their regular appointment at 80 the child and adolescent clinic during the study period were eligible to be included in the study 81 which was a total of approximately 450. However, parents or caregivers of patients older than 18 82 years of age and those of children below 18 who did not consent were excluded from the study. 83 84 Data collection and handling 85 The data collection took place in the child psychiatry outpatient clinic at SQUH while patients 86 were waiting for their appointment. The study was carried out between December 2020 and 87 March 2021. All parents of attendees of the child psychiatry outpatient services at SQUH during 88 the study period were included in the study. Information on the nature and goals of the research, 89 the right to anonymity, and the right to withdraw at any stage with no effect on the clinical care 90 was disseminated to the participants. The questionnaire was offered in Arabic, the first language 91 of most participants, and an English version was an option for the participants who preferred 92 4 filling it in English. It consisted of two parts, namely, socio-demographic and clinical factors, 93 and the data collected included the age, gender, and the diagnosis of the child (neurodevelopment 94 disorder, mood disorder, psychotic disorder, others (epilepsy, genetic syndromes, metabolic 95 syndromes), place of residence (urban, rural), age of parents, marital status (married, divorced, 96 and separated), and educational level of parents; data regarding socioeconomic status (family 97 monthly income) and occupation were also collected. The second part of the questionnaire 98 looked into parents' opinions, knowledge, and attitudes about children's psychotropic 99 medications. Anonymised data were saved on a password-protected electronic database and 100 securely destroyed following the code of conduct for handling research data (UKRIO, 2009). 101 Signed consent forms were stored separately in a locked compartment. 102 103 Sample size calculation and sampling method 104 The required sample size was calculated using MedCal software, allowing for a 95% confidence 105 interval, a 5% type I error, and 80% power. The minimum sample size was calculated to be 260. 106 107 A simple random sampling method was used to recruit the study participants from the list of 108 patients expected to attend the child and adolescent clinic during the study period. Randomiser 109 software generated a list of participants. Those selected randomly and who did not meet the 110 inclusion criteria or opted not to participate were substituted with the next randomly selected 111 participant chosen to fulfil the required sample size. Considering a 20% attrition rate, including 112 non-completed questionnaires and unsigned consent forms, 299 participants were recruited. 113 114 Data analysis: 115 Descriptive statistics, including mean, standard deviation (SD), median, range, frequency, and 116 percentage, were used to report participants' demographic and clinical data and response to the 117 use of children's psychotropic medications. The dependent variable is from one attitude question: 118 "If your child experienced psychiatric symptoms, would you first consult a FH before consulting 119 a psychiatrist? Yes/No'. Those parents who replied 'Yes' were categorised as the 'Prefer FH' 120 group, and otherwise as the 'Non-FH' group. Univariate comparison between the two groups 121 (Yes vs No) was evaluated using Chi-square / Fisher's exact test to explore demographic, 122 clinical, and other attitudes variables. Those variables with p < 0.05 in the univariate analysis 123 5 were included in the multivariate logistic (Wald) regression for further analysis to identify the 124 risk factors associated with the ‘Prefer FH’ group. All statistics, including the Odds ratio (OR) 125 with 95% confidence intervals (CI), were obtained by the Statistical Package for the Social 126 Sciences (SPSS), version 27.0 (IBM SPSS Inc. Chicago, IL, USA), set at a 5% level of 127 significance. 128 129 Ethical approval 130 Ethical approval was granted by the College of Medicine and Health Sciences at Sultan Qaboos 131 University, Muscat, Oman. The study was conducted as per the Declaration of Helsinki and the 132 American Psychological Association regarding human ethical research, including confidentiality, 133 privacy, and data management. Written informed consent was obtained from the participants. 134 135 Results 136 Profile of the participants 137 Details of the profiles of the respondents are shown in Table 1. A total of 299 parents and 138 caregivers agreed to participate in the study, with a response rate of 95% (299/314). The basic 139 demographic breakdown of the respondents was 117 (39.1%) fathers, 156 (52.1%) mothers, and 140 26 (8.7%) other caregivers. The majority of the fathers (75%, n=223) had a high school 141 certificate or higher, almost 40% (n=119) ranged between 30 to 40 years old, and most (77.3% 142 n=231) were employed. The majority of the mothers (76%, n=228) had a high school certificate 143 or higher, more than half (52.8%, n=158) were between 30 to 40 years old, and more than half 144 were unemployed (59.2%, n=177). The majority of the parents were living in an urban area 145 (81.3%, n=243), were married (91.6%, n=274), and more than half of them had a monthly 146 income of up to OMR 1,000 (56%, n=170). For the children, there were more male patients 147 (68.2%, n=204) than females (31.8%, n=95). The majority had an age range of below 10 years 148 old (44.9%, n=134), and more than (74%, n=224) had a diagnosis of neurodevelopmental 149 disorders, followed by psychotic disorder (13.7%), mood disorder (8.7%), and other conditions 150 like epilepsy (3.6%). Tables 2 shows the response to questions on attitudes towards psychotropic 151 medications, the majority of them replied that they did not suffer from a psychiatric disorder 152 (86.3%, n=258), had never taken any psychiatric medications (88.3%, n=264), had no family 153 member with a psychiatric illness (66.2%, n=198), and had no family member who had taken 154 6 any psychiatric medications (67.9%, n=203). Regarding the beliefs the respondents had about the 155 use of psychotropic medicines in children, 44% (n=132) believed that these medications lead to 156 addiction in children, 27% (n=82) thought that they cause brain damage, and 28% (n=85) had 157 concerns about the serious side effects of these medications. The majority of the respondents 158 (92%, n=274) preferred psychotherapy as the first step of treatment for their children. However, 159 82% (n=244) agreed to give their child psychotropic medications if necessary, whereas 25.4% of 160 them (n=76) would consult a FH before consulting a psychiatrist if their child experienced 161 psychiatric symptoms. 162 163 Risk factors associated with parents preferred folk healer 164 Table 3 shows the univariate and multivariate (logistic) analysis of the demographic and attitudes 165 towards psychotropic medications variables associated with a preference to consult a FH. In the 166 univariate analysis, the results showed that marital status (p=0.010), monthly income (p<.001), 167 education level (p=0.026), and employment status (p=0.026) of the mother were linked to a 168 negative attitude towards the use of psychotropic medications in children (p<.001) and were 169 significantly associated with parents who would prefer to consult a FH. 170 171 In the multivariate analysis shown in Table 4, the logistic (Wald) regression showed that marital 172 status, monthly income, and attitudes towards giving psychotropic medications to their children 173 if necessary were significant risk factors for parents to prefer to consult a FH. According to the 174 Hosmer-Lemeshow goodness-of-fit test (χ2=0.567, p=0.967), the model had a good fit with a 175 predicting power of 65.9%. Married parents were 14 times (OR=14.5, p=0.011) more likely to 176 consult a FH than were separated/divorced parents. Those parents with a monthly income below 177 500 OMR and between 500-1,000 OMR were two times (OR=2.5, p=0.016) and three times 178 (OR=3.2, p<.001), respectively, more likely to prefer to consult a FH than were those with a 179 monthly income of more than 1,000 OMR. Regarding the attitude question, parents who 180 disagreed with giving psychotropic medications to their children were three times (OR=3.7, 181 p<.001) more likely to consult a FH than were parents who agreed to give psychotropic 182 medications to their children if necessary. 183 184 Discussion 185 7 Over the past decades, there has been a rise in the prescription of psychotropic medications for 186 mental health difficulties in children and adolescents. 13Oman is a country with a predominantly 187 youthful population, and its economic growth and rapid demographic shift are witnessing a surge 188 in young people with mental health problems. 14Yet, many do not seek care from qualified mental 189 health professionals. 15However, since the development of child and adolescent mental health 190 services (CAMHS) in Oman in the late 1990s, several challenges have emerged, specifically, the 191 maldistribution and scarcity of services for young people and the lack of a mental health act. 116,17 192 This study identified parents’ and caregivers' attitudes and concerns about using psychiatric 193 medications for children attending the CAMHS in SQUH. In this study, one of the caregivers' 194 central beliefs regarding psychotropic medicines was that they lead to addiction, which was present 195 in 44% (n=132) of the respondents, which echoes the findings of other studies. 8,9 Similarly, close 196 to 28% (n=85) of the respondents believed that the medications may lead to toxic and severe side 197 effects, which is in line with a plethora of studies in the literature with similar findings. 18,19 198 Regarding treatment modalities, the majority of the respondents preferred psychotherapy as a 199 treatment for their children, and this is consistent with the results of international studies in which 200 parents chose counselling as the first line of treatment and believed it to be beneficial and to have 201 fewer risks compared to medications. 20 202 203 Furthermore, although the vast majority of parents agreed they would give medications to their 204 children if necessary, 25.4% (n=76) of them would first consult an FH, probably due to the socio-205 cultural beliefs and social stigma associated with mental disorders. 21In our study, parents who 206 disagreed with giving psychotropic medications to their children were three times (OR=3.7, 207 p<.001) more likely to consult an FH than were parents who agreed to prescribe psychotropic 208 medications to their children if necessary. Therefore, consulting an FH before accessing mental 209 health services causes a treatment delay and probably may result in negative mental health 210 consequences. 21 On analysing the sociodemographic factors associated with consulting an FH 211 prior to a psychiatrist, we found that marital status, unemployment, lower income, and lower 212 education level had significant associations. In addition, the existing literature suggests that being 213 single was associated with a higher tendency to visit an FH. 22Still, in our study, the finding was 214 the opposite, as married couples were more likely to consult FHs; however, this is not necessarily 215 8 accurate, as more than 90% of the parents in this study were married, and the overall prevalence 216 of single-parent families in Oman is low. 217 218 Moreover, the results of our research showed that respondents with the education of grade 12 or 219 lower were more likely to consult FHs, and the same applied to those with lower income and 220 unemployment; this concurs with studies done elsewhere. 23Furthermore, it is common for those 221 living in low and middle-income countries to access FHs; 24however, Oman is a high-income 222 country, yet, based on the findings of our study, it remains influenced by such practices. 223 Therefore, even in wealthier countries, the relative popularity of FHs and alternative medicine 224 should be scrutinised in the context of broader social, cultural, and religious perspectives, as 225 local values and beliefs influence people in making such decisions, 25 which confers with a 226 crucial national-level study conducted in Oman suggesting underutilization of health care 227 services in people with mental health difficulties 26 Finally, in Oman and the wider Arab region, 228 there is a need for culturally-specific psychoeducation to address the contextual and socio-229 religious factors and the stigma to improve access to mental health services. 27,28 230 231 Despite sharing emerging information from Oman, the study has some limitations. Because of the 232 social stigma, some responses given by parents, particularly in relation to personal or family 233 history with regard to psychiatric problems, might be unreliable and should be treated with caution. 234 Conducting the study in a city like Muscat, although people from other parts of Oman were 235 included, may have missed a large proportion of the wider Omani community. Moreover, it is 236 essential to acknowledge that the study is subjective and quite a bit of the finding depend on the 237 parents' opinions which different factors could influence. 238 239 Conclusion 240 Most parents agreed they would give their children psychotropic medications if deemed 241 necessary. However, a sizeable proportion of parents and caregivers preferred to consult an FH 242 before accessing mental health services. Parents' opinions and beliefs on psychotropic 243 medications are not in line with the scientific facts. Concerted efforts and increased awareness 244 are needed to address parents' concerns regarding the safety and effectiveness of psychotropic 245 medications in children to improve treatment outcomes. Moreover, incorporating psychosocial 246 9 and behavioural interventions, parent training, and psychiatric rehabilitation must be an integral 247 part of the holistic approach to managing the mental health difficulties of children and young 248 people. Overall, mental health professionals play a significant role in promoting the best 249 practices in the Middle East region and offering psychoeducation to parents and caregivers on 250 the safe use and side effects of psychiatric medications in children, and them in shared decision-251 making about medication regimens. 252 253 Authors’ Contribution 254 HM designed the study, drafted and critically reviewed the manuscript. SAH, MAS, TAM, and 255 MAB collected the data, while MFC analysed the data and interpreted the results. AAH revised 256 the manuscript. All authors approved the final version of the manuscript. 257 258 Conflicts of Interest 259 The authors declare that there are no conflicts of / or competing interests. 260 261 Funding 262 This research received no specific grant from any funding agency in the public, commercial, or 263 not-for-profit sectors. 264 265 References 266 1. Unwin GL, Deb S. Efficacy of atypical antipsychotic medication in the management of 267 behaviour problems in children with intellectual disabilities and borderline intelligence: a 268 systematic review. Res Dev Disabil. 2011 Nov-Dec;32(6):2121-33. doi: 269 10.1016/j.ridd.2011.07.031. 270 2. Cortese S, Adamo N, Del Giovane C, Mohr-Jensen C, Hayes AJ, et al. Comparative 271 efficacy and tolerability of medications for attention-deficit hyperactivity disorder in 272 children, adolescents, and adults: a systematic review and network meta-analysis. 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Basic demographic profile of the parents/caregivers/child (n=299) Demographic n (%) Demographic n (%) Child’s gender Place of residence Boy 204 (68.2) Urban 243 (81.3) Girl 95 (31.8) Rural 56 (18.7) Age (years) of the child Marital status of the parents <= 10 134 (44.9) Married 274 (91.6) 11-15 94 (31.4) Separated 13 (4.3) > 15 71 (23.7) Divorced 12 (4.0) Diagnosis of the child Income per month (OMR) Neurodevelopmental disorder 224 (74.9) < 500 69 (23.1) Mood disorder 26 (8.7) 500-1,000 101 (33.8) 13 Psychotic disorder 41 (13.7) 1,001-2,000 74 (24.8) Other (e.g., epilepsy) 8 (2.7) > 2,000 55 (18.4) Age (years) of father Age (years) of mother < 30 7 (2.3) < 30 20 (6.7) 30-40 119 (39.8) 30-40 158 (52.8) 41-50 119 (39.8) 41-50 113 (37.8) > 50 54 (18.1) > 50 8 (2.7) Education level of father Education level of mother Illiterate to grade 11 76 (25.4) Illiterate to grade 11 71 (23.7) Grade 12 98 (32.8) Grade 12 105 (35.1) Diploma and above 125 (41.8) Diploma and above 123 (41.1) Employment status – father Employment status - mother Employed 231 (77.3) Employed 102 (34.1) Unemployed 13 (4.3) Unemployed 177 (59.2) Retired 55 (18.4) Retired 20 (6.7) Respondents Father 117 (39.1) Mother 156 (52.2) Other caregiver 26 (8.7) 357 Table 2. Frequency of responses to the questionnaire on attitudes towards the prescription of psychotropic medications in children Q1. Would you agree to give your child psychotropic medications if necessary? Q2. Do you suffer or have you suffered from a psychiatric disorder? Yes 244 (81.6) Yes 41 (13.7) No 55 (18.4) No 258 (86.3) 14 Q3. Have you ever taken psychiatric medication? Q4. Has any member of your family experienced a psychiatric disorder? Yes 35 (11.7) Yes 101 (33.8) No 264 (88.3) No 198 (66.2) Q5. Has any member of your family taken psychiatric medication? Q6. What is your concern regarding the use of psychotropic medication in children? Yes 96 (32.1) It causes addiction 132 (44.1) No 203 (67.9) It causes brain damage when used for long periods. 82 (27.4) It has serious side effects. 85 (28.4) Q7. If your child were diagnosed with a psychiatric disorder, would you prefer your child to receive psychotherapy before being started on medication? Q8. If your child experienced psychiatric symptoms, would you first consult a folk healer before consulting a psychiatrist? Yes 274 (91.6) Yes 76 (25.4) No 25(8.4) No 223 (74.6) 358 Table 3. Univariate and multivariate (logistic) analysis showing the association between respondents’ attitude towards consulting a folk healer and demographic factors Q8. Preferred to consult a folk healer Univariate# Multivariate~ Yes (n=76, 25.4%) No (n=223, 74.6%) Factor n (%) n (%) p-value OR p-value 15 Demographic Respondents Father 33 (43.4) 84 (37.7) 0.794 Mother 35 (46.1) 121 (54.3) 0.354 Other caregiver (ref) 8 (10.5) 18 (8.1) Child’s gender Boy 54 (71.1) 150 (67.3) 0.540 Girl (ref) 22 (28.9) 73 (32.7) Age (years) of the child <= 10 30 (39.5) 104 (46.7) 0.485 11-15 27 (35.5) 67 (30.0) 0.781 > 15 (ref) 19 (25.0) 52 (23.3) Diagnosis of the child Neurodevelopmental disorder 53 (69.7) 171 (76.7) 0.404^ Mood disorder 8 (10.5) 18 (8.1) 0.997^ Psychotic disorder 12 (15.8) 29 (13.0) 0.687^ Other (e.g., epilepsy) (ref) 3 (3.9) 5 (2.2) Place of residence Urban 57 (75.0) 186 (83.4) 0.105 Rural (ref) 19 (25.0) 37 (16.6) Marital status of the parents Married 75 (98.7) 199 (89.2) 0.010 14.512 0.011* Separated/divorced (ref) 1 (1.3) 24 (10.8) Income per month (OMR) <500 18 (23.7) 51 (22.9) 0.098 2.519 0.016* 500-1,000 37 (48.7) 64 (28.7) <.001 3.185 <.001* >1,000 (Ref) 21 (27.7) 108 (48.4) Age (years) of father <=40 37 (48.7) 89 (39.9) 0.211 41-50 28 (36.8) 91 (40.8) 0.645 16 > 50 (ref) 11 (14.5) 43 (19.3) Education level of father Illiterate to grade 11 23 (30.3) 53 (23.8) 0.227 Grade 12 26 (34.2) 72 (32.3) 0.484 Diploma and above (ref) 27 (35.5) 98 (43.9) Employment status – father Unemployed/retired 20 (26.3) 48 (21.5) 0.389 Employed (ref) 56 (73.7) 175 (78.5) Age (years) of mother <=40 45 (59.2) 133 (59.7) 0.967^ 41-50 29 (38.2) 84 (37.7) 0.986^ > 50 (ref) 2 (2.6) 6 (2.7) Education level of mother Illiterate to grade 11 19 (25.0) 52 (23.3) 0.258 Grade 12 34 (44.7) 71 (31.8) 0.026 Diploma and above (ref) 23 (30.3) 100 (44.8) Employment status – mother Unemployed/retired 58 (76.3) 139 (62.3) 0.026 Employed (ref) 18 (23.7) 84 (37.7) 359 Table 4. Univariate and multivariate (logistic) analysis on respondents’ attitude towards consulting a folk healer in association with using psychotropic medications in children Univariate# Multivariate~ p-value OR p-value Q1. Would you agree to give your child psychotropic medications if necessary? No 25 (32.9) 30 (13.5) <.001 3.754 <.001* Yes (ref) 51 (67.1) 193 (86.5) Q2. Do you suffer or have you suffered from a psychiatric disorder? Yes 8 (10.5) 33 (14.8) 0.350 17 No (ref) 68 (89.5) 190 (85.2) Q3. Have you ever taken psychiatric medication? Yes 8 (10.5) 27 (12.1) 0.711 No (ref) 68 (89.5) 196 (87.9) Q4. Has any member of your family experienced a psychiatric disorder? Yes 26 (34.2) 75 (33.6) 0.927 No (ref) 50 (65.8) 148 (66.4) Q5. Has any member of your family taken psychiatric medication? Yes 24 (31.6) 72 (32.3) 0.909 No (ref) 52 (68.4) 151 (67.7) Q6. What is your concern towards the use of psychotropic medication in children? It causes addiction. 39 (51.3) 93 (41.7) 0.076 It causes brain damage when used for long periods. 21 (27.6) 61 (27.4) 0.291 It has serious side effects (ref). 16 (21.1) 69 (30.9) Q7. If your child were diagnosed with a psychiatric disorder, would you prefer your child to receive psychotherapy before being started on medication? Yes 68(89.5) 206(92.4) 0.287 No (ref) 8(10.5) 17(7.6) #, 2 test; ^, Fisher's Exact test; *, sig., p<0.05; Ref: reference point; OR, Odds ratio; , Logistic (Wald) regression: Hosmer & Lemeshow test ( 2=0.567, p=0.967); Nagelkerke R square=0.176; Sensitivity=60.5%, Specificity=65.8%, Overall=65.9% 360