Developing child mental health services in developing countries

Diagnostic efficiency and psychometric properties of CBCL DSM-oriented scales in a large sample of Chinese school-attending students aged 5-16

BACKGROUND

Children and adolescents are vulnerable to various psychiatric disorders during the critical phase of individual development. In China, the child behavior checklist (CBCL) is a widely employed psychometric questionnaire for assessing children and adolescents. However, further validation of the psychometric properties and diagnostic effectiveness of the CBCL DSM-oriented scales is necessary. These scales were developed based on DSM diagnosis and require evaluation using a substantial sample of Chinese individuals.

METHODS

This study involved the analysis of a substantial dataset consisting of 72,109 samples collected from five provinces in China. Data was gathered using the CBCL (Parent Rating Scale), and rigorous assessments of reliability and validity were conducted. The mini-international neuropsychiatric interview for children and adolescents (MINI-KID) and the diagnostic and statistical manual of mental disorders-IV (DSM-IV) interview were employed to diagnose the participants. To ensure the accuracy of the diagnoses, receiver operating characteristic curve (ROC curves) were utilized, and the Youden Index was calculated to determine the appropriate diagnostic cut-off point for each specific target diagnosis.

RESULTS

The study included a total sample of 72,109 cases, out of which 19,782 cases underwent MINI-KID assessment and structured or semi-structured interviews based on DSM-IV to clarify the diagnosis. Reliability and validity analyses showed that the reliability of the subscales and total scales was good, except for Anxiety Problems. The Cronbach's alpha for the CBCL DSM-oriented scales was 0.92. In addition, the validity of all scales was good (CFI = 0.80). For the sample with a clear diagnosis, all five subscales of the CBCL DSM-oriented scales showed fair diagnostic efficiency for the target diagnosis. Among them, the area under curves (AUC) of Mood disorder, Anxiety, Attention deficit and hyperactivity disorder (ADHD), Oppositional defiant disorder (ODD) and Conduct disorder (CD) are 0.80, 0.74, 0.75, 0.74, 0.74. Among the three sample groups, the highest diagnostic efficiency was found in Affective Problems to Mania. The diagnostic cut-off point for each subscale on target diagnoses was clearly defined.

CONCLUSION

Overall, the reliability, validity and diagnostic efficiency of CBCL DSM-oriented scales in Chinese children and adolescents were within acceptable limits. In addition, we used ROC curves and cut-off points to predict the cut-off values of common child and adolescent psychiatric disorders mentioned in the CBCL DSM-oriented scales. This provides an important reference for the clinical application of the CBCL DSM-oriented scales in Chinese samples.

Mental health of transitional aged youth in Nicaragua: Perceptions and experiences of educators

Mental illnesses contribute to a large proportion of the disease burden in children and adolescents in low and middle-income countries (LMICs). There is limited research completed in LMICs about paediatric mental health, particularly related to youth. School is a place where many adolescents first seek mental health support. This study examined how educators in Nicaragua view youth mental health and how mental health can be supported in LMIC schools. Focus groups were completed with teachers serving youth from a variety of socioeconomic settings within León, Nicaragua. The study was completed from an Interpretivist theoretical paradigm and coding of qualitative data was completed consistent with Constructivist Grounded Theory. Educators described their roles in as detecting mental health problems and liasing with other supports; they noted barriers as cross-sector integration and social challenges. Educators felt that youth would be better served by improving integration of care, addressing structural factors, and providing more teacher supports. A model for addressing youth mental health in LMICs could include a stepped-care approach with schools providing preventative programming as well as developing within school referral strategies for youth with higher needs. There may be a role for the use of community health promoters.

Child and adolescent mental health services in Pakistan: current situation, future directions and possible solutions

Worldwide, mental disorders are on the increase (Gadit, 2007) and an estimated 10-20% of children have one or more mental or behavioural problems (Park, 2002). There is an urgent and serious need to pay attention to the mental health needs of children in low- and middle-income countries (Rahman et al, 2000). The initial survey for the World Health Organization's Atlas project (Sherer, 2002) showed that 41% of countries surveyed had no mental health policy and 28% had no separate budget for mental health.

Parents' perspectives on care of children with autistic spectrum disorder in South Asia - Views from Pakistan and India

Autism spectrum disorder (ASD) affects about 1.4% of the population in South Asia but very few have access to any form of health care service. The objective of this study was to explore the beliefs and practices related to the care of children with ASD to inform strategies for intervention. In Pakistan, primary data were collected through in-depth interviews of parents (N = 15), while in India a narrative review of existing studies was conducted. The results show that the burden of care is almost entirely on the mother, leading to high levels of stress. Poor awareness of the condition in both family members and front-line health-providers leads to delay in recognition and appropriate management. There is considerable stigma and discrimination affecting children with autism and their families. Specialist services are rare, concentrated in urban areas, and inaccessible to the majority. Strategies for intervention should include building community and family support networks to provide respite to the main carer. In the absence of specialists, community members such as community health workers, traditional practitioners and even motivated family members could be trained in recognizing and providing evidence-based interventions. Such task-shifting strategies should be accompanied by campaigns to raise awareness so greater inclusivity can be achieved.

Quality of life and human rights conditions in a public psychiatric hospital in Cairo

Purpose

– There is no documented evidence on service users’ perceptions of quality of care and observance of human rights in mental health residential facilities in Egypt after the new mental health law passed in 2009. The purpose of this paper is to investigate El-Abbassia Mental Health Hospital in Cairo. Special attention is paid as to the variety of human rights violations which are experienced by the users and the context in which these violations occur.

Design/methodology/approach

– A cross-sectional study was performed relying on 36 depth interviews with patients, 58 staff members and 15 family members, reviews of documents and observations by an independent assessment team consisting of the author, another psychiatrist, a nurse and a family member using the World Health Organization Quality Rights Tool Kit which uses the Convention on the Rights of Persons with Disabilities (CRPD) as its framework.

Findings

– The study reported empirical insights into how the steps taken by the hospital to address several of the themes drawn from the CRPD require either improvement or initiation to comply fully with the convention’s themes.

Research limitations/implications

– Respondents may have failed to disclose their true experiences due to fear of punishment.

Practical implications

– Users admitted to mental hospitals have often been forgotten, thus becoming victims of violence, neglect and other human rights violations.

Social implications

– An opportunity to promote public awareness of the rights of patients.

Originality/value

– The importance of this study came from being the first documented evidence on service users’ perceptions of quality of care and observance of human rights in mental health residential facilities in Egypt after the new mental health law passed in 2009.

Prevalence of behavioral and emotional problems among seven to eleven year old children in selected schools in Kandy District, Sri Lanka

BACKGROUND

Behavioral and emotional problems comprising internalizing, externalizing and mixed disorders consist of psychiatric disorders in childhood and adolescents. Prevalence rates of 8.3% for preschoolers, 12.2% for preadolescents and 15.0% for adolescents have been reported from around the world. This study aimed to measure the prevalence of emotional and behavioral disorders in 7-11 year-old school children studying in Kandy District Sri Lanka which was a first for the geographic area.

METHOD

This was a community based study at the primary section of the selected schools. The questionnaire, Child behavior Checklist-Sinhala (CBCL-S) was administered in a group setting to the main caregiver of 562 subjects selected randomly. The questionnaire identified problems in 8 subscales under three main sub categories : internalizing, externalizing and other. Data were analyzed using The Syndrome Scales for Boys and Girls developed for analyzing the questionnaire CBCL.

RESULTS

Indicated a prevalence of 13.8% of emotional and behavioral problems in the study population. 8.8% of children showed internalizing problems and 8.8% externalizing problems. These findings are in line with the prevailing rates from previous studies of the world. Children in school types 1AB and 1C had less emotional and behavioral problems compared to type 2 and 3 schools.

LIMITATIONS

Only 20 schools in KEZ and Sinhala speaking population of the Kandy were studied.

CONCLUSIONS

This study showed the extent of childhood emotional and behavioral problems and also confirms that the schools with advanced level classes have lesser problems amongst primary children.

Mental health services for individuals with high functioning autism spectrum disorder

Adolescents and adults with an autism spectrum disorder (ASD) who do not have an intellectual impairment or disability (ID), described here as individuals with high-functioning autism spectrum disorder (HFASD), represent a complex and underserved psychiatric population. While there is an emerging literature on the mental health needs of children with ASD with normal intelligence, we know less about these issues in adults. Of the few studies of adolescents and adults with HFASD completed to date, findings suggest that they face a multitude of cooccurring psychiatric (e.g., anxiety, depression), psychosocial, and functional issues, all of which occur in addition to their ASD symptomatology. Despite this, traditional mental health services and supports are falling short of meeting the needs of these adults. This review highlights the service needs and the corresponding gaps in care for this population. It also provides an overview of the literature on psychiatric risk factors, identifies areas requiring further study, and makes recommendations for how existing mental health services could include adults with HFASD.

Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries

BACKGROUND

Little is known about the treated prevalence and services received by children and adolescents in low- and middle-income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs.

METHODS

The World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), a 155-indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower-middle, and 5 upper-middle-income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO-AIMS instrument.

RESULTS

The median one-year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health.

CONCLUSIONS

Mental health services for children and adolescents in low- and middle-income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.

A survey of Autism knowledge and attitudes among the healthcare professionals in Lahore, Pakistan

BACKGROUND

The diagnosis and treatment of Autism in Pakistan occurs in multiple settings and is provided by variety of health professionals. Unfortunately, knowledge and awareness about Autism is low among Pakistani healthcare professionals & the presence of inaccurate and outdated beliefs regarding this disorder may compromise early detection and timely referral for interventions. The study assessed the baseline knowledge and misconceptions regarding autism among healthcare professionals in Pakistan which can impact future awareness campaigns.

METHODS

Physicians (psychiatrists, pediatricians, neurologists and family physicians) and non-physicians (psychologists and speech therapists) participated in this study. Knowledge of DSM-IV TR criteria for Autistic Disorder, beliefs about social, emotional, cognitive, treatment and prognosis of the disorder were assessed. Demographic information regarding the participants of the survey was also gathered.

RESULTS

Two hundred and forty seven respondents (154 Physicians & 93 Non-physicians) participated in the study. Mean age of respondents was 33.2 years (S.D 11.63) with 53% being females. Reasonably accurate familiarity with the DSM IV-TR diagnostic criteria of Autistic Disorder was observed. However, within the professional groups, differences were found regarding the utilization of the DSM-IV-TR criteria when diagnosing Autistic Disorder. Non-Physicians were comparatively more likely to correctly identify diagnostic features of autism compared with Physicians (P-value<0.001). Significant misunderstandings of some of the salient features of autism were present in both professional groups.

CONCLUSION

Results suggests that current professionals in the field have an unbalanced understanding of autism due to presence of several misconceptions regarding many of the salient features of autism including developmental, cognitive and emotional features. The study has clinical implications and calls for continued education for healthcare professionals across disciplines with regards to Autism in Pakistan.

Child and adolescent mental health worldwide: evidence for action

Mental health problems affect 10-20% of children and adolescents worldwide. Despite their relevance as a leading cause of health-related disability in this age group and their longlasting effects throughout life, the mental health needs of children and adolescents are neglected, especially in low-income and middle-income countries. In this report we review the evidence and the gaps in the published work in terms of prevalence, risk and protective factors, and interventions to prevent and treat childhood and adolescent mental health problems. We also discuss barriers to, and approaches for, the implementation of such strategies in low-resource settings. Action is imperative to reduce the burden of mental health problems in future generations and to allow for the full development of vulnerable children and adolescents worldwide.

Using the World Health Organization's 4S-Framework to Strengthen National Strategies, Policies and Services to Address Mental Health Problems in Adolescents in Resource-Constrained Settings

BACKGROUND

Most adolescents live in resource-constrained countries and their mental health has been less well recognised than other aspects of their health. The World Health Organization's 4-S Framework provides a structure for national initiatives to improve adolescent health through: gathering and using strategic information; developing evidence-informed policies; scaling up provision and use of health services; and strengthening linkages with other government sectors. The aim of this paper is to discuss how the findings of a recent systematic review of mental health problems in adolescents in resource-constrained settings might be applied using the 4-S Framework.

METHOD

Analysis of the implications of the findings of a systematic search of the English-language literature for national strategies, policies, services and cross-sectoral linkages to improve the mental health of adolescents in resource-constrained settings.

RESULTS

Data are available for only 33/112 [29%] resource-constrained countries, but in all where data are available, non-psychotic mental health problems in adolescents are identifiable, prevalent and associated with reduced quality of life, impaired participation and compromised development. In the absence of evidence about effective interventions in these settings expert opinion is that a broad public policy response which addresses direct strategies for prevention, early intervention and treatment; health service and health workforce requirements; social inclusion of marginalised groups of adolescents; and specific education is required. Specific endorsed strategies include public education, parent education, training for teachers and primary healthcare workers, psycho-educational curricula, identification through periodic screening of the most vulnerable and referral for care, and the availability of counsellors or other identified trained staff members in schools from whom adolescents can seek assistance for personal, peer and family relationship problems.

CONCLUSION

The predominant endorsed action is not that dedicated mental health services for adolescents are required, but that mental health care should be integrated using cross-sectoral strategies into the communities in which adolescents live, the institutions they attend and the organisations in which they participate.

Mental health services for children in public care and other vulnerable groups: implications for international collaboration

Children in public care and other vulnerable young groups (homeless, adopted, refugees) are increasingly becoming the focus of policy and service planning. There is strong evidence that all these client populations have high rates of mental health problems which are closely associated with other needs. We also have good knowledge on the factors that predispose individuals to and maintain mental health problems, as well as on the reasons for their not easily accessing and engaging with services. There is less evidence on the effectiveness of interventions or service models, although some interesting patterns are beginning to emerge. These include the need for inter-agency commissioning, clear care pathways, designated provision, applied therapeutic interventions, training for carers and frontline practitioners, and multi modal programmes. This paper discusses these issues, as well as ways forward, both for systems with relatively well developed child mental health services and for low-income countries. Service quality can be greatly strengthened by international collaboration on policy, practice and research networks, training and research.

Self perception score from zero to ten correlates well with standardized scales of adolescent self esteem, body dissatisfaction, eating disorders risk, depression, and anxiety

The ability to quickly and reliably assess mental health status would assist health workers, educators and youth workers to provide appropriate early intervention for adolescents.

OBJECTIVE

To investigate the validity of a simple self perception score out of ten by correlating the self perception scores of adolescents from a normal, community sample of adolescents with their scores on standardized mental health measures. Study group was 470 early adolescent students aged 11.0-14.5 years from grades 7 and 8 in two secondary schools.

METHODS

Self perception was self reported using a score of zero to ten points, and the scores were then correlated with scores on the Harter Self Perception Profile, Beck Junior Depression, Speilberger State and Trait Anxiety and the Eating Disorders Inventory. A High Risk group (self perception < 5) was assessed to examine how many of these adolescents also had poor self esteem and risk for depression, anxiety, and eating disorders.

RESULTS

Self perception scores correlated positively with self esteem and self concept subscales and it was negatively associated with depression, state and trait anxiety, and EDI scores. Of the 15.1% high risk adolescents in the overall sample, 78% scored below the group average on the mean of all Harter Self Concept scores; 70% scored above average for Beck Depression; 64% and 74% scored above average on Speilberger State/Trait Anxiety respectively; 80% scored higher than the average on the group mean EDI.

CONCLUSIONS

A self perception score from zero to ten can be a simple and accurate way of gaining an initial insight into the current mental health status of adolescents.

Prevalence of emotional and behavioural problems among 6-12 year old children in Egypt

Epidemiological information about prevalence of child mental health problems is essential to inform policy and public health practice. This information is weak in many developing countries and those in developmental transition. There have been few such studies in Arab countries and none in Egypt. We conducted a population prevalence study of emotional and behavioural disorders among 1186 6-12 year old children in Minia, Egypt. Data was collected from teachers and parents using the Strengths and Difficulties Questionnaire with a 98 and 91% response respectively. Prevalence of abnormal symptom scores is reported for both parents and teachers. Prevalence of probable psychiatric diagnoses was measured using the SDQ multi-informant algorithm. These prevalences have then been compared to published UK data. The prevalence of emotional and behavioural symptoms was high as reported by both parents and teachers (Abnormal total difficulties: teachers 34.7% (95% CI 32.0-37.5), parents 20.6% (18.2-23.2). Abnormal prosocial scores: teachers 24.9% (22.5-27.5), parents 11.8% (9.9-13.9)) but prevalence of probable psychiatric diagnoses was much lower (Any psychiatric diagnosis 8.5% (6.9-10.5); Emotional disorder 2.0% (1.2-3.0); Conduct disorder 6.6% (5.1-8.3); Hyperactivity disorder 0.7% (0.3-1.4)). Comparison with UK data showed higher rates of symptoms but similar rates of probable disorders. Despite public, professional and political underestimation of child mental health problems in Egypt, rates of symptoms are higher than in developed countries, and rates of disorders are comparable. These findings support greater investment in community and primary care prevention and treatment initiatives.

Primary care treatment for child and adolescent neuropsychiatric conditions in remote rural Punjab, Pakistan - a cross-sectional survey

BACKGROUND

Pakistan is one of the most populous regions of the world. Previous work has demonstrated that there is reliance on traditional healthcare systems when seeking psychiatric care; however, there is a lack of information on help seeking for child and adolescent population. The aim of this study was to describe types of treatments and families' perceptions of the effectiveness of those treatments for childhood neuropsychiatric disorders in remote rural Punjab.

METHOD

Cross-sectional survey of consecutive attendees at an advertised mental health consultation day in a remote rural area.

RESULTS

The effectiveness of these treatments, as rated by patients and their families, was variable, with highest reported effectiveness for general practitioner treatments. In families with a past history of care from a general practitioner, those who had epilepsy reported treatments to be more effective than those with mental retardation. Carers and users described consulting five different types of primary healthcare practitioners that used both physical and psychotherapeutic treatments.

CONCLUSIONS

There is considerable variation in treatments available for child and adolescent neuropsychiatric disorders in remote rural areas of Punjab, a large proportion of which are considered ineffective by the users and carers. This highlights the need to develop effective interventions for child and adolescent neuropsychiatric conditions that can be administered by primary health workers. Our data suggest that the need for this is greatest for mental retardation.

Developing child mental health services in resource-poor countries

Despite significant gains in tackling the major causes of child mortality and evidence of an urgent need for child mental health services, resource-poor countries continue to lag behind in child and adolescent mental health service development. This paper analyses possible barriers to the development of child mental health services in resource-poor countries and attempts to proffer solutions. Obstacles identified are the magnitude of child mental health problems that remain invisible to policy makers, an absence of child mental policies to guide the process of service development, and overburdened child mental health professionals. The belief systems about mental illness also prompt help seeking in alternative health systems, thereby reducing the evidence for the burden associated with health seeking. Solutions that may support child mental health service development are the provision of adequate advocacy tools to reveal the burden, poverty alleviation, health awareness programmes, enforcing legislation, training centred within the region, and partnerships with professionals in developed countries. These solutions require simultaneous approaches to encourage service development and utilization. Reductions in child mortality in resource-poor countries will be even more dramatic in the years to come and preparations need to be made to take care of the mental health needs of the children who will survive.

Worldwide child and adolescent mental health begins with awareness: a preliminary assessment in nine countries

To temper untoward mental health outcomes in children and adolescents, the World Psychiatric Association's Presidential Global Child Mental Health Programme, in collaboration with the WHO and the International Association of Child and Adolescent Psychiatry and Allied Professionals, established a Child Mental Health Awareness Task Force headed by Sam Tyano. Its task was to develop methodologies to increase awareness among policy-makers, community leaders, health professionals, teachers, parents, and children. Based on a prior comprehensive international search for effective techniques for information dissemination, an awareness manual was written for use by health professionals in diverse communities so as to guide the design and implementation of location specific awareness campaigns. We assessed the children, parents and teachers both before and after the campaign to determine changes in knowledge, attitudes and understanding of mental health. The school-based studies were conducted in selected communities in nine countries on five different continents distinguished by their different languages, cultures and their differing levels of economic development: Armenia, Azerbaijan, Brazil, China, Egypt, Georgia, Israel, Russia, and Uganda. In the six sites that completed all assessments, indicators of positive change in awareness of child mental health were identified, and results demonstrated an increased willingness to discuss emotional problems freely. These data support the utility of collaborating with schools so as to foster better child mental health in such under-resourced communities.

Assessment of need for a school-based mental health programme in Nigeria: perspectives of school administrators

The majority of children in Nigeria are unable to access mental health services. In this resource-poor setting, a school-based mental health service can be used to reach children who would otherwise not have access. An essential first step in the development of a school-based mental health programme is a needs assessment. Key informants (KIs) from southwest Nigeria were interviewed to identify their perspectives on child mental illness and needs for a school mental health programme. Data were analysed using interpretative phenomenological analysis. Although KIs sometimes used derogatory terms to describe mental illness, they were able to give full descriptions of different kinds of mental illnesses in children and a range of causes based on the bio-psychosocial model of disease. KIs acknowledged deficiencies in their training even though they currently use parent, child and environment-centred interventions to deal with mental health problems in school. KIs reported teachers as comfortable with handling mental health issues in children and suggested interventions that included development of basic and ongoing training. Barriers, such as poverty, ignorance and stigma need to be addressed, while government involvement and enlightenment campaigns are critical components of a successful programme.

The prevalence of psychiatric disorders among 5-10 year olds in rural, urban and slum areas in Bangladesh: an exploratory study

BACKGROUND

No previous epidemiological studies of child mental health have been conducted in Bangladesh, partly due to lack of suitable measures.

METHODS

A Bangla translation of a standardised child psychiatric interview, the Development and Well-Being Assessment (DAWBA), was validated against routine clinical diagnoses on a consecutive series of 100 referrals to a child mental health service. A two-phase study of prevalence was applied to random samples of 5- to 10-year-olds (N=922) drawn from three contrasting areas: a rural area, a moderately prosperous urban area, and an urban slum.

RESULTS

There was substantial agreement between the DAWBA and the independent clinic diagnosis (kappa=0.63-0.94). The estimated prevalence of any ICD-10 diagnosis was 15% (95% CI 11-21%). The rate of obsessive-compulsive disorder was higher than in previous studies. Children from the slum area were significantly more likely to have serious behavioural problems, and marginally more likely to have post-traumatic stress disorder.

CONCLUSION

A conservative extrapolation is that around 5 million Bangladeshi children and adolescents have psychiatric disorders. In a country with very few child mental health professionals, there is a vast gap between need and provision that must be addressed.