could be other features.

These include agitation,

pseudodementia, psychomotor retardation, hypochondriacal Differences between
preoccupation and delusional thoughts. Symptoms of
depression (for example poor appetite, constipation and Western and African
sleep difficulties) are commonly found in the elderly, which
makes diagnosis difficulU3 Management is the same as for models of psychiatric
depression in younger adults, but includes management of
the additional problems associated with ageing, such as illness
housing and problems of daily living. Lower doses of
antidepressants may be required and occasionally A case study
electroconvulsive therapy is recommended. A major feature
is the psychosocial management; this involves a team G. M. Behr, C. W. AJlwood
approach using all available community resources. l l

African and Western illness models differ dramatically.

Conclusion
It is certainly within the scope of any general practitioner to
treat nearly all the depressive disorders, except for the most
severe, and this fact has not been emphasised sufficiently in
the past.
General practitioners could achieve much by simply
heightening their awareness of depression and its somatic
presentations. Early recognition and adequate treatment
could lead to great improvement in the quality of life of many
patients who might otherwise suffer needlessly.
The treatment of mood disorders is rewarding for the
general practitioner. Because the prognosis is good,
optimism is always warranted and welcomed by both the
patient and his family.
The overwhelming majority of black psychiatric patients
are exposed to both Western psychiatry and traditional
healing and somehow have to integrate the different
approaches to causation and management of their
problem. This case study compared the assess~ent of
four psychiatric inpatients by a traditional healer with that
of the psychiatrists. The study attempted to describe the
similarities and differences in respect of method of
assessment and causation, treatment and prognosis of the
affliction. These preliminary findings seemed to indicate
that the differences were far more significant than the
similarities.

REFERENCES
S At, Med J 1995; 85: 580-584.

1. Capstick A.. Recognition of emotional disturbance and the prevention of suicide.

BMJ 1960; 1: 1179-1182.
2. Barractough B, Bunch J, Nelson B, Sainsburg P. A hundred cases of suicide:
clinical aspects. Br J Psychiatry 1974; 125: 355-373. In South Africa two major models of illness causation are
3. Fahy T J. Pathways of specialist referral of depressed patients from general
practice. B,J Psychiatry 1974; 124: 231-239. prevalent. There is the Western (biomedical) model which
4. Arreghini E. Agostini C, Wilkinson G. General practitioner referral to specialist
psychiatric services: a comparison of practices in north and south Verona.
ascribes illness to chance, heredity or lifestyle, and the
Psychol Med 1991; 21: 485-494. traditional African model which explains all events in terms
5. Perez-Stable EJ, Miranda J, Munoz RF. Depression in medical outpatients. Arch
Intern Med 1990; 150: 1083-1087. of God, ancestors, pollution and witchcraft.'
6. Regier DA, Boyd JH, Burke JO, et al. One-month prevalence of mental disorders
in the United States. Arch Gen Psychiatry 1988; 45: 977-986.
South African traditional healers (THs), such as diviners,
7. Wilkinson G. Depression: Recognition and Treatment in General Practice. Oxford: herbalists and faith healers, use the latter model both
Radcliffe Medical Press, 1989.
8. Kaplan HI. Sadock BJ. Comprehensive Textbook of Psychiatry. 5th ed. Baltimore: diagnostically and therapeutically, although they may well
Williams & Wilkins, 1989.
9. Feighner JP, Boyer WF. The Diagnosis of Depression: Perspectives in Psychiatry. differentiate natural from supernatural causation. 2 ,3 THs are
Chichester: John Wiley & Sons, 1991: 2. widely consulted by both urban and rural black South
10. Suchan T. Depression in African patients. S Afr Med J 1969; 23: 1055-1058.
11. Pearse PAE, Hays RB, Pond CD. Depression in general practice. Med J Austr Africans of all c1asses.4-0 Furthermore it has been suggested
1992; 157: 38-41.
12. Gagiano CA. Depression and community care. CME 1992; 10(3): 361-367. that consultation of THs for psychological disturbance is
13. Montgomery SA. Anxiety and Depression. Petersfield: Wrightson Biomedical, 1990. higher than for somatic/physical ailments. 7 A survey
14. Goldberg D. Identifying psychiatric illness among general medical patients. BMJ
1985; 291: 161-162. conducted among certified patients at Sterkfontein Hospital
15. Keller MB. Depression: underrecognition and undertreament by psychiatrists and
other health care professionals. Arch Intern Med 1990; 150: 1083-1088. (G. M. Behr - unpublished research) revealed that fully
16. American Psychiatric Association. Diagnostic and Statistical Manual at Mental 75% had consulted a TH at some point in their illness and
Disorders. 4th ed. Washington, DC: APA, 1994.
17. Beaumont G. Diagnosis and management of depression in general practice. S Atr 67% indicated that they intended to continue to do so in
Med J 1992; suppl. 1-4.
18. Schatzberg AFJ. Recent development in the acute somatic treatment of major future.
depression. Clin Psychiatry 1992; 53(3): suppl. 20-25. If one considers these figures and the relative ratios of TH
19. Leclere H, Beaulieu MD, Bordage G, Sindom A, Couillard M. Why are clinical
problems difficult? General practitioners' opinions concerning 24 Clinical to population (1 :500)4 against doctor to population (between
problems. Can Med Assoc J 1990; 143: 1305-1315.
20. Freeling P, Rao BM Paykel ES, Sireliog U, Burton RH. Unrecognised depression 1:100 000 and 1:150 000 in some South African rural areas),·
in general practice. BMJ 1985; 290: 1880-1883.
21. lIiffe S, Haines A, Gallivan S, SooroH A, Goldenberg E, Morgan P. Assessment of
elderly people in general practice, social circumstances and mental state. Br J
Gen Pract 1991; 41: 9-12.
22. Bowers J, Jorm AF, Henderson S, Harris P. NH & MRC Social Psychiatry
Research Unit, Australian National University Canberra. Aust NZ J Psychiatry
1992; 26: 168-174. Department of Psychiatry, University of the Witwatersrand,
23. Pond CD, Mant A, Bridges-Webb C, et al. Recognition of depression in the Johannesburg
elderly: a comparison of general practitioner opinions and the geriatric
depression scale. Fam Pract 1990; 7: 190-194. G. M. Behr. M.B. B.CH.• Registrar

Accepted 3 Dee 1993. C. W. AIlwood. M.D. (PSYCH.)

Volume 85 No, 6 June 1995 SAMJ

-
it is clear that the vast majority of 'healing' in our society is
done by THs.
Our society is in transition and for most black South
Africans this means having to integrate the Western world
view and, specifically, the Western model of illness
causation into their own world view. For many, a mystical
causation is ascribed to mental illness even if, as often
happens, a dual diagnosis·,·,'Q is accepted, i.e. assessment
and treatment by both Western and traditional medicine.
Efficacy of THs
Very little research has been done into the efficacy of
traditional healing' and this has been described mostly in
anthropological and psychological terms.",,·,3 Despite this, it
seems likely that the large numbers of people who attend
THs do so because there is some perceived benefit. Besides
the medicinal properties which some of the traditional
remedies may possess (Watt and Breyer-Brandwijk in
Hammond Tooke' suggest that only 5% do), much emphasis
has been placed on the fact that THs explain the meaning'
of the disease, and answer questions like 'why me?'''''' and
'by whom?'" - a form of 'psychotherapy'.
Psychiatrists in South Africa are increasingly seeing
psychiatric problems which, until recently, were probably
seen only by THs. It is also proposed that THs be included
in the health service, and Littlewood'· suggests that the
discipline of clinical anthropology be developed to address
these problems. Currently, however, it seems appropriate
and important for psychiatry to try to understand how South
African THs perceive psychiatric illness.
Objectives
This study is an attempt to describe a TH's assessment of
psychiatric patients and to illustrate themes. The issues
examined include: (I) method of assessment; (if) formulation
of the patient's problem and its management; (iif)
assessment of severity and prognosis; (iv) attitude toward
psychiatric treatment.
Methods
The research took the form of a case study of a TH who
assessed four psychiatric inpatients at Sterkfontein Hospital,
a psychiatric hospital. The sample was chosen from patients
who were sufficiently recovered to give consent. All had
been treated and observed in hospital for at least 1 month.
The psychiatric diagnoses had been made according to
DSM-JII-R criteria. The assessment was conducted behind a
one-way mirror, with G.M.B. observing. Each assessment
lasted 20 - 30 minutes and the TH was then interviewed
about the illness, its cause, severity and prognosis, and her
treatment plan and her attitude to psychiatric treatment of
that patient. Translation was undertaken by two nursing
sisters, one of whom is herself a qualified TH.
SAMJ
P S Y C H' I A TRY
Results
Case 1
A 44-year-old Zulu woman had a diagnosis of bipolar mood
disorder. She presented with classic manic features and
responded well to treatment. At the time of assessment by
the TH, the patient was not psychotic and her mood was
only marginally elevated.
TH assessment
The patient's complaints were noted as being physical
('distended stomach', 'wheezy chest', 'headaches') but the
TH asserted that these were caused by the patient's
ancestors who had also repeatedly caused her to become
mentally ill. She said that her mental illness was not an
'inborn thing'. The 'dollars' (bones, shells, domino pieces
and other items thrown by the TH) had shown her that the
patient's ancestors had chosen her to do their work and that
she had to train (thwasa) to be an isangoma (TH) herself.
She informed the patient, who knew only that her mother
had left her, that her mother had, in fact, died. Because the
patient was unaware of her mother's whereabouts or the
location of the grave (this was, in fact, true), she was distant
from her ancestors and possessed by an evil spirit. Once
she had located her ancestor's graves, she had first to
perform certain duties to awaken her ancestors so that she
could then undergo thwasa. The TH asserted that once the
patient had undergone thwasa, she would no longer require
treatment. The value of Western psychiatric treatment was
seen to be containment of symptoms until training was
completed.
Case 2
A 59-year-old Tswana woman had a diagnosis of chronic
schizophrenia. She had had an acute relapse (probably due
to non-compliance) and presented with mainly negative
features of schizophrenia. .
At the time of the TH's assessment the patient was not
psychotic but had negative symptoms of schizophrenia with
poverty of thought, blunted affect and poor self-care.
TH assessment
The patient had been chosen by two of her ancestors to
do their work at an early age. The patient had ignored these
calls and her ancestors had turned away from her, allowing
evil spirits to enter. These were of two kinds, izilwane and
amafufunyane. Jzilwane are evil creatures which force the
person to do bad things and cause people to hate them.
Amafufunyane is possession by evil spirits which cause
'madness' and disturbed behaviour. These have to be
cleansed far from any home because of the risk of
contaminating others. These evil spirits had manifested as
physical ailments: tired heart, swollen feet, unendurable pain
in the side and falling without having tripped, which could
lead to epilepsy. At a certain point she could easily have
been helped, and had consulted many isangoma who had
just given her beads instead of purifying her. To start at the
beginning would cost a lot and even if this were done, one
would still have to struggle with the physical problems, The
SAMJ Volume 85 No, 6 June 1995 m.
 TH said that she should just be maintained on psychiatric
treatment. The 'dollars' showed that the patient would die
within weeks or months. This was said to the researcher but
not to the patient, and as far as is known did not happen.
Case 3
A 30-year-old Tswana man had a diagnosis of bipolar mood
disorder and his current presentation was with severe mania.
His response to treatment had been very slow and at the
time of the interview he was still intrusive with mildly
elevated mood and delusions.
TH assessment
The TH said that this had nothing to do with witchcraft.
His problem was lifelong and a consequence of poor
parenting, which had led to his abusing alcohol and
cannabis at a young age; this had aggravated the problem.
His condition had also been worsened by his being
poisoned by a friend with whom he was competing at work.
(The psychiatrists had no collateral evidence to confirm this.)
The TH felt his condition would never improve beyond what
had already been achieved. She felt he would relapse very
soon and that there was little value in ongoing psychiatric
care. She felt she could give him traditional medicine to
calm him down but little else. Although the patient asserted
that he was a TH, she told him clearly that this was not so
and that he could never be one because his ancestors were
too weak.
Case 4
A 24-year-old Swazi man was referred to Sterkfontein from
a general hospital where he had been medically stabilised
following a head injury 2 weeks previously. He had
undergone computed tomography which had shown a
resolving cortical haemorrhage. He had become very
aggressive and confused and was therefore referred to the
hospital. He recovered well on haloperidol and at the time of
interview his behaviour was appropriate, he had insight and
was performing well at occupational therapy. A diagnosis
was made of organic mental syndrome not otherwise
specified.
TH assessment
The TH said that this man's family used to believe in the
ancestors and do their work, and that one of the patient's
ancestors (after whom he was named) had been a TH.
However, the family had ceased to do this work.
Furthermore, the patient had left home to come to
Johannesburg without telling anyone and without asking his
ancestors' permission. These factors had led some people
at home to bewitch him so that he lost his ancestors'
protection and had an accident which caused his mental
illness. (The TH mentioned the accident without having any
prior knowledge or evidence of it.) She said that he would
have another accident and relapse if he did not go home,
trace all his elderly living relatives and do his ancestors'
. work at his birthplace. She said that if he did this he would
not get sick again and that he would need psychiatric
treatment only until he did this.
Volume 85 No. 6 June 1995 SAMJ
Discussion
This study is limited in that it examines only one TH. Most
sources agree that the variation in style between different
healers is very significant. Information which can be
generalised must be gathered in studies of larger numbers
of THs and their assessments of the same patient.
Understanding the nuances of what is being
communicated is very important in this type of research.
Consequently, the use of a translator had obvious
drawbacks and reading the transcribed interviews brought
home to the author the inadequacy of this process. (That
this is the means by which most patients who speaK only an
African language have a psychiatric diagnosis made, is an
issue which needs to be addressed.)
Comparison of method of assessJ11ent
In all the TH's assessments she threw the 'dollars;;. Although
she noted physical symptoms reported by the pati~nt, she
made no attempt to elicit psychological symptoms. Neither
did she take into account the patients' observed fnental
state in her assessment.
She elicited certain information by asking the patient to
confirm or deny her statements, which were occasionally
startlingly accurate despite the lack of evidence (e.g. her
first question to patient 3, whose delusions were all
concerned with wealth, was, 'Why are you so concerned
about money?'). She also had no way of knOWing that
patient 4 had had an accident.
In the community, the presence of the family and their
reactions to the statements may give the TH some
diagnostic clues. Clearly that influence was minimised in this
context.
Formulation of the problem
The interpretation of reported symptoms
Both patients 1 and 2 were noted by the TH to have
extensive physical problems but these were attributed to the
same mystical cause as their mental illness, i.e. psyche and
soma reflecting a single underlying problem. Neither had
been noted by the doctor to have any medical problem, but
this phenomenon is consistent with the tendency of black
patients to express psychological problems in terms of
somatic complaints, as well as the indivisibility of psyche
and soma in the traditional African illness model.
Causation
In cases 1, 2 and 4, the TH gave a 'mystical' causation for
the illness. In case 3 (bipolar mood disorder) the TH did not
invoke any 'mystical' causation but two 'natural' causes
(substance abuse and poisoning) and a psychosocial factor
(poor upbringing). This was paradoxical because the
causative factors listed by the TH are frequently cited in
psychiatry, but we had no evidence to support these in this
particular patient. Meaningful comparisons could be made,
though, because the causative factors are in the vocabulary
of psychiatry. This contrasts with the views of some
authors",1. who feel that the diagnostic paradigm is so
different that valid comparisons cannot be made between
psychiatrists' and THs' diagnoses.

Patient 4 was assessed as having organic mental
syndrome not otherwise specified with a confusional state
directly related to his head injury. The TH felt that the
'accident' was the direct cause of his problem but that this
had been allowed to happen because his disrespect for his
ancestors had led to the withdrawal of their protection and
his bewitchment.
Therefore, although the assessments were similar, the TH
had also provided the reason for his 'accident'. In all cases
the TH provided the meaning of the illness - the 'why me?'
and 'by whom?' - citing mainly neglect of ancestors and
interpersonal conflict.
The TH's assessment of cases 1 and 2 differed radically
from the psychiatric assessment in that biological factors
were excluded. No similarities were noted in the TH's
assessment of the two patients diagnosed as having bipolar
disorder. Buhrmann 12 cites five illness categories used by a
Xhosa TH. Three of these terms were used by the TH to
describe the patients in this study and the descriptions of
these afflictions (amafufunyane, bewitchment and thwasa)
were similar in both studies. Attempts have been made to
describe the phenomenology of folk categories of
illness",7,12,'9.20 but the South African examples have not been
well elaborated. This study group was too small to help in
this regard.
Concepts of causation were described by Wessels 3 and
Hammond-Tooke' and these correlated very well with those
put forward by the TH in this study. The findings of this
study contradict the assertion by some South African
authors3 " that a cle.<lr definition of 'natural' illness exists
among THs and that biomedical treatment is considered
appropriate for this group of patients.
Assessment of severity and prognosis
The TH considered major psychiatric problems to be well
within the scope of her ability. This is not in keeping with the
findings of other authors7 "o,11 that THs confine themselves to
treating neurotic or psychosocial problems.
In cases 1 and 4 the TH predicted total remission once
the patients had fulfilled obligations to the ancestors, at
which point they would no longer require psychiatric
treatment. The psychiatric assessment of their prognosis
depended on their continuing psychiatric treatment for
control, but a 'cure' seemed unlikely.
In patient 2 the TH predicted imminent death (from the
configuration of the 'dollars'), but saw the irreversibility of
the patient's problem as due partly to her not having enough
money for the treatment. It was not clear (to the authors)
whether her prognosis would have changed if she had had
enough money.
Patient 3 (bipolar) was expected by the psychiatrist to
have a prognosis at least as good as patient 1 (bipolar), yet
the TH felt he would get no better than he was at present,
and that his condition would probably worsen.
Patients 2 and 3 received a poorer prognosis than 1 and
4. The former were also the only two to have disturbed
thought and behaviour at the time of the interview. Although
the assessment was ostensibly by means of the 'dollars',
this may have influenced her assessment.
In terms of overall severity and prognosis, both our
assessment and that of the TH saw patient 2 as the most
PSYCHIATRY
serious case. However, it was difficult to isolate criteria or
indicators common to both assessments which determined
this. Furthermore, little congruence with regard to indicators
of prognosis emerged in respect of cases 1, 3 and 4. It
seems, therefore, that there may be very little overlap in the
assessment of high-risk groups.
Attitude toward psychiatric treatment
In all cases the value of psychiatric treatment was seen by
the TH to be containment of the illness. The TH felt that
once the underlying cause had been addressed (in patients
1 and 4 particularly) psychiatric treatment would no longer
be necessary. If the psychiatrists' assessment is correct and
that of the TH wrong then such patients are likely to relapse
as a consequence of the advice of their TH. However, she
made a point of encouraging all the subjects to continue
taking their medication at this point.
Conclusions
What emerges very clearly from this limited study is that the
differences between traditional African and Western
assessments of psychiatric patients are much more marked
than the similarities. This has significant implications for the
two-thirds or more of our psychiatric patients who consult a
TH. These people are caught between two worlds, two
views of their problem, its causation and its management.
This TH did not feel that these were mutually exclusive, but
pointed out that other THs do. Many patients would
probably seize the opportunity to stop taking drugs; this
would most probably result in early relapse.
What is more difficult to comment upon is the positive
effect of an alternative explanatory and therapeutic model
for psychiatric patients. The persistence of traditional
healing, despite the availability of Western medicine,
probably implies that it fulfils some need. This 'efficacy',
however, is difficult to measure, though this would be very
desirable."
Although there are probably advantages to unifying
traditional and Western psychiatric care, we may have to
conclude, as Ben-Tovim does in the light of his experience
in Botswana,'s that the two systems are best left to function
independently. The efforts of health workers and planners
should be directed at fostering mutual respect and
facilitating patients' utilisation of both systems.
The authors would like to thank Professor W. D. Hammond-
Tooke for his invaluable assistance and advice. Nursing sisters
Miriam Molefe, Constance Mojapelo and especially Sindiswa
Nkosi were instrumental in carrying out the research and aiding
our understanding. We express our gratitude to Ms Joanne
Stein for clarifying methodological issues, and our most sincere
thanks to the traditional healer, Thoko Qekeni, whose
participation was motivated purely by the desire to further our
understanding of traditional healing.
REFERENCES
1. Hammond-Tooke WO. Rituals and Medicines. Johannesburg: AD Donker, 1989.
2. Nkosi SA. The utilisation of mental health education of families of psychiatric
patients on traditional health practice versus Western psychiatric treatment.
Submitted to Rand Afrikaans University for M.Cur. degree, 1991.
3. Wessels WHo Cultural psychiatry: theory and practice. CME 1985; 3(12): 23-26.
SAMJ Volume 85 No. 6 June 1995
 4. Abdool Karim SS, Ziqubu-Page T, Arendse R. Bridging the gap: potential for a
health care partnership between African traditional healers and biomedical
personnel in South Africa. S Afr Med J 1994; 84(12): Insert.
Exposure to violence in
5. Edwards SO. Traditional and modern medicine in South Africa: a research study.
Soc Sc; Med 1986; 22: 1273-1276.
6. Farrand D. Is a combined Western and traditional health service for black
patients desirable? S Afr Med J 1984; 66: 779-780.
children referred for
7. Mohmann AA, Richeport M, Marriott BM, Canino GJ, Rubio-Stipec M, Bird H.
Spiritism in Puerto Rico. Br J Psychiatry 1990; 156: 328-335.
8. Rispel L, Behr G. Health Indicators: Policy Implications. Joh~nesburg: Centre for
psychiatric evaluation
Health Policy, University of Witwatersrand, 1992.
9. Cheetham RWS, Griffiths JA. Changing patterns of psychiatry in South Africa.
S Atr Med J 1980; 56: 166-168.
R. J. Nichol, G. Joubert, C. A. Gagiano
10. Hirst MM. The Healer's Act~ Cape Nguni diviners in the townships of
Graharnstown. Ph.D. thesis, Rhodes University, 1990.
11. Kleinman A, Sung LH. Why do indigenous practitioners successfully heal? Soc One hundred consecutive patients referred to the Child
Sci Med 1979; 138: 7-26.
12. Buhrmann MV. Uving in Two Worlds. Pretoria: Human and Rousseau, 1984. Mental Health Section of Oranje Hospital in Bloemfontein
13. Holdstock TL. Indigenous healing in South Africa: a neglected potential. South
African Journal of Psychology 1979; 9: 118-124. for psychiatric evaluation were included in the study.
14. Oaynes G, Msengi NP. Why am I ill? Who made me ill? The relevance of Western
psychiatry in Transkei. S Afr Med J 1979; 56: 307-308.
Seventy-four per cent of children in the study reported
15. Ben-Tovim 01. Development Psychiatry, London: Tavistock Publications, 1987. exposure to some form of violence in the past: 32%
16. Uttlewood A. From categories to contexts: a decade of the 'new cross-cultural
psychiatry'. Br J Psychiatry 1990; 56: 308-327. reported exposure to domestic violence, 9% disciplinary
17. Kiernan JP. Is the witchdoctor medically competent? S Afr Med J 1977; 53: 1072-
1073. violence, 15% violent crime, 2% political violel1fe, 24%
18. Uttlewood R, lipsedge M. Aliens and Alienists. Ethnic Minorities and Psychiatry.
2nd ed. London: Unwin Hyman, 1989. sexual violence and 25% other forms of violen.ce. Political
19. Robertson BA, Kottler A. Cultural issues in the assessment of Xhosa children and
adolescents. S Afr Med J 1993; 83: 207-208. violence did not feature prominently in the study.
20. Beiser M, Ravel J, Collomb H, Engelhoff C. Assessing psychiatric disorder <
amongst the Serer of Senegal. J Nerv Ment Dis 1972; 154: 141-151. S Afr Med J 1995; 85: 584-586.

Accepted 15 Feb 1995.

In South Africa, violence and the effects of violence feature

prominently in the media. D. Lewis' has described violence
as prevalent in every group of people, regardless of
ethnicity, race or religion. M. Lewis2 defined violence as
'behaviour by one person intended to cause pain, damage
or destruction to another'. 2
Within the South African context very little medical
information on the effects of violence on children is
available. Single studies have been pUblished describing
work done in certain communities."" Butchart and co-
workers5 feature a few children in their study on non-fatal
injuries caused by interpersonal violence in Johannesburg-
Soweto. Most of the findings, however, are dominated by
adult statistics. Parry and Yach 6 quote 1988 mortality
statistics for South Africa (excluding the TBVC states) which
indicate that violence and trauma cause the most deaths in
South Africa. These deaths must have a profound effect on
the families (including children) of the victims.
The present study was undertaken to establish the nature
and effects of violence within the local context by studying a
group of children referred for psychiatric evaluation.

Method
The Child Mental Care Centre of Oranje Hospital in
Bloemfontein is a tertiary referral unit that serves the whole
Orange Free State region. Children and families have access
to psychiatric care at peripheral clinics and hospitals in the
region. Initially, patients are referred to the unit or peripheral
clinics by general practitioners. In this study, consecutive
children referred to the Centre for psychiatric evaluation

Department 9f Psychiatry and Division of Biostatistics, University of

the Orange Free State, Bloemfontein
R. J. Nichol. M.B. CH.B., D.P.H., M.MED. (psYCH.)
G. Joubert. BA, B.SC. HONS
C. A. Gagiano, M.B. CH.B., M.MED. (psyCH.), M.D.

Volume 85 No. 6 June 1995 SAMJ