Awareness about Autism among Primary Healthcare Providers in Oman: A Cross-Sectional Study

BACKGROUND: Many developing countries such as Oman are marred with the rising tide of children with autism and the lack of specialized services for these children. Within existing compartmentalized and centralized health care organizations, the general practitioners (GPs) are likely to serve as the first level of contact relevant for diagnosis and referral for remedial services. This study aims to explore the awareness of autism among GPs in Oman on issue pertinent to etiology, signs and symptoms, perceived correlates, as well as the consequence of having autism. Related to this is to examine whether years of medical practice would invariably influence GPs’ awareness. METHODS: This cross-sectional study was conducted among GPs (n=113) working at primary healthcare centers (PHC) during September 2013 to February 2014 in Muscat, the capital of Oman.RESULTS: The GPs appear to have suboptimal awareness of etiological factors relevant for the development of autism, its common signs and symptoms, perceived correlates, as well as the social dimension. Number of years in practice has little bearing on awareness.CONCLUSION: Empirical evidence has unequivocally indicated that although there is no known ‘cure’ for autism, early identification and early intervention tend to better the quality of life for children with autism. This means GPs in Oman should be fitted with adequate awareness of such population.

Profile of Mental and Behavioral Disorders Among Preschoolers in a Tertiary Care Hospital in Oman: A Retrospective Study

OBJECTIVES

Early diagnosis and prompt treatment of mental and behavioral disorders in preschoolers is critical for a better prognosis, ultimately leading to improved quality of life for both the child and the family. Our study investigated the clinical profile of mental and behavioral disorders in children < 7 years of age, seeking consultation at Sultan Qaboos University Hospital, Muscat, Oman, between 1 June 2006 and 31 December 2010. The objective was to explore demographic variables, intervention types, and annual trends.

METHODS

This retrospective, descriptive study was conducted by reviewing the electronic records of preschoolers seeking consultation on mental and behavioral disorders at the Department of Behavioral Medicine. The diagnosis was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria.

RESULTS

The total number of cases was 466, the majority (77.9%) being boys. The cumulative frequencies and annual hospital-based prevalence rates were estimated for each category of mental and behavioral disorders. Our findings showed increased service utilization among preschoolers, as reflected in the annual trend and case-specific prevalence rates. While comorbidity was common, the most frequent disorders encountered were attention deficit hyperactivity disorder (70.8%), developmental language disorder (23.6%), autism spectrum disorders (20.2%), and disruptive behavior disorders (11.6%). The most commonly prescribed drugs/supplementation were risperidone (18.7%), atomoxetine (9.7%), omega-3 (8.8%), and methylphenidate (6.2%).

CONCLUSIONS

Consultations for mental and behavioral disorders are being sought for Omani preschoolers. Beside pharmacotherapy, other interventions, which are an integral part of a much desired multidisciplinary approach should be introduced. Readdressing the missing needs is essential for a comprehensive approach to managing mental and behavioral disorders.

Stress, anxiety, and depression among parents of children with autism spectrum disorder in Oman: a case-control study

Previous studies carried out in Euro-American populations have unequivocally indicated that psychological disorders of the CASD (caregivers of children with autism spectrum disorder) are marked with high levels of stress, anxiety, and depression. This finding has been attributed to the reaction of having to care for a child with neurodevelopmental disorders. While there have been reports on autism spectrum disorder in Arab/Islamic countries such as Oman, there is no study from this region, to our knowledge, reporting the performance of indices of stress, anxiety, and depression among CASD. This study aimed to examine whether there is variation in the performance of indices of stress, depression, and anxiety explored via Depression, Anxiety and Stress Scale 21 among CASD, caregivers of children with intellectual disabilities, and caregivers of typically developing children. All indices of stress, depression, and anxiety were higher in CASD compared to other caregivers in the control group. This study corroborates with other studies carried out in other populations that caring for children impacts the mental health status of caregivers. Therefore, there are strong grounds to contemplate the mechanism to help such a vulnerable group of family caregivers.

Decreased glutathione and elevated hair mercury levels are associated with nutritional deficiency-based autism in Oman

Genetic, nutrition, and environmental factors have each been implicated as sources of risk for autism. Oxidative stress, including low plasma levels of the antioxidant glutathione, has been reported by numerous autism studies, which can disrupt methylation-dependent epigenetic regulation of gene expression with neurodevelopmental consequences. We investigated the status of redox and methylation metabolites, as well as the level of protein homocysteinylation and hair mercury levels, in autistic and neurotypical control Omani children, who were previously shown to exhibit significant nutritional deficiencies in serum folate and vitamin B12. The serum level of glutathione in autistic subjects was significantly below control levels, while levels of homocysteine and S-adenosylhomocysteine were elevated, indicative of oxidative stress and decreased methionine synthase activity. Autistic males had lower glutathione and higher homocysteine levels than females, while homocysteinylation of serum proteins was increased in autistic males but not females. Mercury levels were markedly elevated in the hair of autistic subjects vs. control subjects, consistent with the importance of glutathione for its elimination. Thus, autism in Oman is associated with decreased antioxidant resources and decreased methylation capacity, in conjunction with elevated hair levels of mercury.

Unusual trichobezoar of the stomach and the intestine: a case report

INTRODUCTION

Trichobezoars are an infrequent form of bezoar found in the stomach or intestine, created from ingested hair. This condition has been well described in the surgical literature, but less reported in psychiatry.

CASE PRESENTATION

We describe the case of an 18-year-old Middle Eastern Caucasian woman with trichotillomania who presented to our emergency department with a history of central abdominal pain associated with vomiting and constipation for five days. An examination showed a trichobezoar requiring emergent surgical intervention, and indicating the need for psychiatric treatment. The trichobezoar was treated successfully by laparotomy.

CONCLUSION

The medical and psychiatric sequelae of trichotillomania should not be underestimated, and early diagnosis and treatment is of utmost importance to save the patient's life and prevent recurrence. Although laparotomy is still considered an excellent option, pharmacotherapy and behavioral assessment play a useful role in patient management. Our case highlights the fundamental concept of a holistic approach rather than only treating the symptoms, by considering factors such as genetic influences to understand the disease.

Variation in socio-economic burden for caring of children with autism spectrum disorder in Oman: caregiver perspectives

A cross-sectional study was conducted to investigate whether caregiver's variations in socioeconomic status (SES) has direct bearing on challenges of nurturing children with autism spectrum disorder (ASD) in Oman. A cadre of caregivers (n = 150) from two types of SES (low-income and middle-high income) were compared based on four domains: (1) accessing and perception of remedial services, (2) utilization and perception of psychiatric services, (3) constraints for being a caregiver of children with ASD and (4) financial expenses of taking care of children with ASD. There is little indication that any particular SES fare well on these domains. Factors to mitigate such predicaments are therefore imperative in order to improve quality of life for caregivers among children with ASD.

Impact of nutrition on serum levels of docosahexaenoic acid among Omani children with autism

OBJECTIVES

Autism is a lifelong neurodevelopmental disorder of early childhood. Dietary supplementation of the ω-3 fatty acid (docosahexaenoic acid [DHA]) during prenatal and postnatal life is considered a protective dietary intervention strategy to minimize the risk for autism spectrum disorder (ASD). To our knowledge, no relevant studies have been conducted in the Middle East investigating the status of DHA among children with autism during early childhood. The aim of this study was to investigate the serum levels and dietary intake status of DHA among Omani children recently diagnosed with ASD.

METHODS

The present case-control study involved 80 Omani children (<5 y), 40 cases and 40 controls matched for age and sex. A semi-quantitative food frequency questionnaire was used to assess dietary intake of all the participants, while serum levels of DHA were measured using high-performance liquid chromatography.

RESULTS

Our results showed that children with ASD had lower dietary consumption of foodstuff containing DHA, as well as lower serum levels of DHA than controls.

CONCLUSION

The present finding from Oman supports the view of other studies that there are low serum levels of DHA among children with ASD.

Levels of heavy metals and essential minerals in hair samples of children with autism in Oman: a case-control study

Toxic levels of heavy metals and low levels of essential minerals have been suggested to play a critical role in the pathogenesis of autism spectrum disorders (ASD). This study documents the levels of heavy metals and essential minerals in hair samples of children with ASD in Muscat, the urbanized capital of Oman, Muscat. The study included 27 children with ASD and 27 matched non-ASD controls. Parental interviews were held and dietary intake questionnaires completed in conjunction with the collection of hair samples. Analysis of heavy metals and essential minerals was carried out by inductively coupled plasma mass spectrometry. Chi-square analysis and non-parametric Fisher's exact tests were used to assess statistical significance. Children with ASD had significantly higher levels of all 11 analyzed heavy metals in their hair samples (P < 0.05), ranging from 150 to 365 % of control levels. ASD children also had significantly higher levels of essential minerals sulfur, sodium, magnesium, potassium, zinc, and iron, but lower levels of calcium and copper in their hair samples. This study corroborates data from previous studies in different parts of the world indicating the presence of elevated levels of heavy metals and selective depletion of essential minerals in the hair of children with ASD.

Increased markers of oxidative stress in autistic children of the Sultanate of Oman

Autism spectrum disorder (ASD) is a neurodevelopmental disorder of early childhood, and an enumeration about its etiology and consequences is still limited. Oxidative stress-induced mechanisms are believed to be the major cause for ASD. In this study 19 autistic and 19 age-matched normal Omani children were recruited to analyze their degree of redox status and a prewritten consent was obtained. Blood was withdrawn from subjects in heparin-coated tube, and plasma was separated. Plasma oxidative stress indicators such as nitric oxide (NO), malondialdehyde (MDA), protein carbonyl, and lactate to pyruvate ratio were quantified using commercially available kits. A significant elevation was observed in the levels of NO, MDA, protein carbonyl, and lactate to pyruvate ratio in the plasma of Omani autistic children as compared to their age-matched controls. These oxidative stress markers are strongly associated with major cellular injury and manifest severe mitochondrial dysfunction in autistic pathology. Our results also suggest that oxidative stress might be involved in the pathogenesis of ASD, and these parameters could be considered as diagnostic markers to ensure the prevalence of ASD in Omani children. However, the oxidative stress-induced molecular mechanisms in ASD should be studied in detail.

Hyperhomocysteinemia among Omani autistic children: a case-control study

High serum homocysteine (Hcy) level is regarded as an indicator for impairment of folate-dependent methionine cycle and is associated with oxidative stress. In a case control study, we evaluated eighty 3-5 years old Omani children (40 diagnosed with Autism Spectrum Disorder and 40 their age and gender matched controls) for their fasting serum homocysteine levels as a biomarker of Autism Spectrum Disorder (ASD). Serum folate and vitamin B(12) status were also evaluated. The serum homocysteine was measured using an enzyme immunoassay (EIA) technique whereas folate and vitamin B(12) were measured using an automated random access immune-assay system. The results indicated that mean serum Hcy levels were significantly (P < 0.05) higher in autistic children (20.1 ± 3.3 µmol/L) as compared to controls (9.64 ± 2.1 µmol/L). Significantly (P < 0.05) lower serum folate (1.8 ± 0.4 µg/L) and vitamin B(12) (191.1 ± 0.9 pg/mL) levels were observed in autistic children as compared to controls (6.1 ± 0.6 µg/L and 288.9 ± 1.3 pg/mL, respectively). The levels of homocysteine in autistic children were also much higher as compared to normal reference values (5-15 µmol/L). The results suggest that high fasting serum homocysteine and low folate and vitamin B(12) levels could be used as clinical biomarkers for an early diagnosis and management of ASD.

Hyperhomocysteinemia among Omani autistic children: a case-control study

High serum homocysteine (Hcy) level is regarded as an indicator for impairment of folate-dependent methionine cycle and is associated with oxidative stress. In a case control study, we evaluated eighty 3-5 years old Omani children (40 diagnosed with Autism Spectrum Disorder and 40 their age and gender matched controls) for their fasting serum homocysteine levels as a biomarker of Autism Spectrum Disorder (ASD). Serum folate and vitamin B(12) status were also evaluated. The serum homocysteine was measured using an enzyme immunoassay (EIA) technique whereas folate and vitamin B(12) were measured using an automated random access immune-assay system. The results indicated that mean serum Hcy levels were significantly (P < 0.05) higher in autistic children (20.1 ± 3.3 µmol/L) as compared to controls (9.64 ± 2.1 µmol/L). Significantly (P < 0.05) lower serum folate (1.8 ± 0.4 µg/L) and vitamin B(12) (191.1 ± 0.9 pg/mL) levels were observed in autistic children as compared to controls (6.1 ± 0.6 µg/L and 288.9 ± 1.3 pg/mL, respectively). The levels of homocysteine in autistic children were also much higher as compared to normal reference values (5-15 µmol/L). The results suggest that high fasting serum homocysteine and low folate and vitamin B(12) levels could be used as clinical biomarkers for an early diagnosis and management of ASD.

Characteristics of ADHD among Omani schoolchildren using DSM-IV: descriptive study

BACKGROUND

There is a dearth of studies describing the characteristics of ADHD among schoolchildren attending child psychiatry clinics in the Arab world. Most of the previous quests have focused on community surveys or themes that hampered international comparison.

AIM

This study screened for the presence of ADHD as well as investigates the psychosocial and educational history relevant for the diagnosis of ADHD among children.

METHOD

Consecutive schoolchildren attending child psychiatric consultations were screened for the presence of ADHD according to the Diagnostic and Statistical Manual for Mental disorders (DSM) criteria.

RESULT

A total of 221 schoolchildren suffering from ADHD were identified according to the DSM. The year incidence was 0.16. Males constituted the majority presenting with ADHD. The contribution of consanguinity and a history of acquired brain injury were common features. The majority were attending mainstream education as pharmacotherapy is the only option available for managing ADHD.

CONCLUSION

This study is one of the few from this part of the world using DSM criteria to diagnose ADHD. The implications of the present findings are discussed in the context of the available literature and the specific situation in Oman.

A strange type of Pica

Pica, where the patient eats non-food items such as mud, clay, varnish etc., is a common behavioural problem seen in children, pregnant women and the mentally retarded. However sponge pica is a very rare variation. We report a case of a 5-year-old Omani girl, who presented with sponge pica since the age of two years, with recent abdominal pain. Investigations showed anaemia, elevated liver enzymes and normal intelligence. There was no evidence of obsessive-compulsive disorder. Both clinical and laboratory findings showed complete recovery after a few weeks of oral iron therapy. Her appetite improved, and she started to gain weight. No recurrence was observed when followed up after two years. Awareness is necessary to detect and treat pica as early as possible to prevent its complications.

Profile of child and adolescent psychiatry in Oman

OBJECTIVE

To find the common behavioral problems in youth, their co-morbidity, treatment, and other variables in Oman.

METHODS

All patients who attended the child psychiatric clinic in Sultan Qaboos University Hospital (SQUH), Muscat, (the only child psychiatry clinic in Sultanate of Oman) for a 3-month period were investigated for behavioral problems, particularly hyperactivity (by Conners' Questionnaire). The diagnosis was based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.

RESULTS

Of the total 212 cases, Omani nationals constituted 89% and the rest were expatriates. Sixty five percent were boys, 57% were of school age, 26% were adolescents, 9% were preschoolers and 5% were toddlers. Consanguinity among their parents was high at 52%. The majority (60%) of the patients exhibited hyperactivity. Aggression was found in 49%, while stealing and lying were found in 25% and 22%. Approximately one-third suffered from headache and abdominal pain. The majority (62%) were of below-normal intelligence. Anxiety affected 14%, depression 4%, and conduct disorders 8%. One-third of the patients were taking psychostimulants and another one-third were taking tricyclics. The results were compared with those from other developing countries.

CONCLUSION

Behavioral problems among children and adolescents are high in Oman, same as other developing countries, though the type of disorders is different here. This calls for the attention of the health policy makers for diagnosing and treating such disorders in Oman as well as in the other developing countries.

Sleep problems among pupils in Benghazi, Libya

OBJECTIVE

To find the prevalence of sleep problems among pupils, its possible causes and associated behaviors.

METHODS

This study was carried out during 3-24 February 1996. We randomly selected a sample of (277) 5th graders (181 boys and 96 girls), from 3 public primary schools in 3 different socio-economic areas in Benghazi, Libya. We interviewed the pupils and the teachers by a pretested questionnaire concerning sleep, school achievement and other behaviors. Those pupils who sleep after 10:00 pm, or those having bad sleep characters, or both, twice or more a week in the last month, were considered suffering from sleep problems. According to their performance in the first semester in both Arabic and Mathematics, pupils were classified in to 3 groups (>70% in both the good group, 50-70% in both subjects or in one provided that the other was above 70% the average group, <50% in one or both subjects the poorly achieving group).

RESULTS

This study shows high prevalence of sleep problems among pupils (28.9%), especially in a high-density area, with non-significant gender difference. Associated behaviors are bad school achievement, sleepiness and mood fluctuation.

CONCLUSION

Parental ignorance, unawareness and bad child rearing and follow-up are evident, and considered to be the main cause of these problems, that needs intensive education towards better sleep hygiene.

Deliberate self-poisoning in Oman

OBJECTIVE

To describe the demographics, precipitating factors, substances and methods used for deliberate self-harm in Oman.

METHODS

Data were extracted from the Accident and Emergency (A & E) records of patients treated at the A & E units in Muscat from 1993 to 1998. Data were obtained form the history, and clinical findings resulting form deliberate self-harm.

RESULTS

During the 5-year study period, 123 persons presented to various hospitals in the Muscat area with injuries that resulted form deliberate self-harm. Most of these cases were women, students and unemployed. There was a high incidence of family, marital and psychiatric or social problems. The methods of self-harm were most often analgesics (such as paracetamol) and non-pharmaceutical chemicals.

CONCLUSIONS

The rate of self-injurious behaviour is low in Oman, compared with other countries, including other Islamic countries. The data illustrate a rising rate and a tendency to ingest toxic doses of analgesics or non-pharmaceutical chemicals.

A case of bilateral ptosis with unsteady gait: suggestibility and culture in conversion disorder

We report a case of a 14-year-old girl who presented, following a sudden onset, with bilateral ptosis, gait disturbance, difficulty swallowing and loss of appetite, right hypochondriacal pain, and frontal headache. Protracted neurological and medical examinations were unremarkable; neither was precipitating psychological stresses evident. The condition, which manifest as typical conversion disorder, lasted for one year. "Treatment" involving electrical stimulation of both eyes muscles and legs with positive reassurance resolved the symptom. This case supports the view that conversion disorder, not only involves a strong element of suggestion, but also incorporates socio-cultural sanctioned prescription.

Growth pattern of primary schoolchildren in Benghazi, Libya

OBJECTIVE

To find the growth trends in a sample of schoolchildren in Benghazi (Libya), and to compare it with international and other local growth charts, as a step for setting the national curves.

METHOD

From 25^th February to 31^st October 1993, a sample of 2,022 pupils (1,160 boys and 862 girls) were randomly selected from three public primary schools in three different socio-economic areas in Benghazi. A questionnaire consisting of social and scholastic items was distributed to teachers a few days before the examination. The height and weight of all the pupils were measured according to the standards of Jellife, Gorstein, WHO, and de Onis. Data were analysed and compared with both the reference standard of the United States National Center for Health Statistics (NCHS-USA), and the local standards of Tripoli-1986.

RESULTS

The boys and girls in the lowest age-group had a pattern similar to that of the reference population for both height/age and weight/age, but it dropped sharply from mid-school years. The Benghazi curves were consistently higher than those of Tripoli, particularly for height/age.

CONCLUSION

The nutritional status of these children, which was good before the beginning of schooling, was negatively affected during the school years. This could be attributed either to births in the family and consequent neglect, or to the school's negative effects on the child, such as lack of appetite created by anxiety or other factors. Further studies from different regions of the country are needed to set national growth curves.

Accidental poisoning in children

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