M. K. C. Nair

Motor and mental development of infants exposed to antiepileptic drugs in utero

We prospectively evaluated the mental (MeDQ) and motor (MoDQ) developmental quotients of 395 (67.5% of the eligible) infants of mothers with epilepsy (IME) (mean age: 15 months) enrolled in the Kerala Registry of Epilepsy and Pregnancy between 1998 and 2004. The same developmental pediatricians, blinded to antiepileptic drug (AED) exposure, evaluated the children using the Indian adaptation of the Bayley Scale of Infant Development: Their mean MeDQ was 89.1+/-29.9 and mean MoDQ was 90.7+/-26.9. The MeDQ and MoDQ were impaired (<84) for 150 (37.6%) and 133 (33.5%) IME, respectively. Maternal age, type of epilepsy, seizure frequency, or use of folic acid did not correlate with the mean MeDQ or MoDQ. Maternal education was significantly correlated with the MoDQ, but not with the MeDQ, of the infants. Infants not exposed to AEDs (n=32) had a higher MeDQ (mean: 92.3, 95% CI: 81.4-103.2) and MoDQ (mean 94.7; 95% CI 84.9-104.5) than those exposed to AEDs (MeDQ--mean: 88.6, 95% CI: 85.5-91.6; MoDQ--mean: 90.0, 95% CI: 87.3-92.8). Those exposed to polytherapy had significantly lower developmental quotients than those exposed to monotherapy. Cumulative AED scores during pregnancy had an inverse relationship with developmental quotients. On multiple regression analysis, polytherapy was a stronger predictor of lower developmental quotients than dosage. Compared with carbamazepine monotherapy, valproate monotherapy was associated with significantly lower MeDQ and MoDQ in IME (93.1 and 95 vs 86.9 and 86.1), but the differences between other AEDs were not significant for IME exposed to valproate monotherapy. A limitation of the study is that the influence of maternal intelligence on developmental quotients was not evaluated.

Development and validation of language evaluation scale Trivandrum for children aged 0-3 years--LEST (0-3).

ObjectiveTo develop and validate a simple screening tool which can be used in the Community to identify delay in language development among children of 0–3 years of age.MethodsThe normal range for the 33-items of “Language Evaluation Scale Trivandrum for 0-3years-LEST(0-3)” were carefully selected from various existing language development charts and scales, by experts keeping in mind the face validity and content validity. The criterion validity was assessed using a community sample of 643 children of 0 to 3 years of age, including 340 (52.9%) boys. LEST (0–3) was validated against Receptive Expressive Energent Language Scale, for screening delay in language development among children of 0-3 years.ResultsWhen one item delay was taken as ‘LEST delay’ (test positive), the sensitivity and specificity of LEST(0-3), was found to be 95.85% and 77.5%, respectively with a negative predictive value of 99.8% and LR (negative) of 0.05.When two item delay was taken as ‘LEST delay’ (test positive), the sensitivity and specificity of LEST(0-3), was found to be 66.7% and 94.8% respectively with a negative predictive value of 98.7% and LR (negative) of 0.35. The test-retest and inter-rater reliability were good and acceptable (Interclass correlation of 0.69 for testretest and 0.94 for inter-rater).ConclusionLEST (0–3) is a simple, reliable and valid screening tool for use in the community to identify children between 0-3 years with delay in language development, enabling early intervention practices.

Long-term visual outcome in idiopathic intracranial hypertension

Objective: To characterize the course, outcome, and risk of relapse or late worsening in a clearly defined cohort of idiopathic intracranial hypertension (IIH) over a long period of follow-up. Materials and Methods: Retrospective chart review of patients with definite IIH was evaluated at the Sree Chitra Tirunal Institute for Medical Sciences and Technology between 1998 and 2006. Patients’ demographic data, clinical, neuro-ophthalmic examinations, and treatment details were abstracted. Patients were further categorized into three groups based on whether they improved, worsened, or relapsed on follow-up. Final visual outcome of each patient was defined according to grading of the worse eye at the last visit. Statistical analysis included t test to compare group means and chi-square test to compare proportions. Results: Of the 43 women included, visual impairment was observed in 80 eyes (93%) at presentation and it was moderate to severe in 14%. The mean CSF opening pressure at presentation did not differ significantly in those with visual impairment compared to those with normal vision. Those having early severe visual impairment had significantly higher (P = 0.015) likelihood of severe visual impairment on last follow-up. Of the total, 34 patients (79%) improved, 4 (9.3%) relapsed on follow-up after period of stability, and 5 (11.6%) worsened over 56 months follow-up (range, 26-132 months). The groups were comparable, except those who improved were younger (P<0.05). At last examination, 9% had significant vision loss. Conclusion: IIH patients can have delayed worsening or relapses and about tenth of patients can have permanent visual loss early or late in the course of the disease. All patients with IIH need to be kept under long-term follow-up, with regular monitoring of visual functions.

CDC Kerala 9: Effectiveness of Low Intensity Home Based Early Intervention for Autism Spectrum Disorder in India

ObjectiveTo validate effectiveness of low intensity, home based early intervention (EI) models in autism for countries with low disability resources.MethodsFifty-two toddlers and young children were assessed before and after intervention with Childhood Autism Rating Scale, Vineland Social Maturity Scale, and Receptive-Expressive Emergent Language Scale. Developmental and speech therapists helped mothers assemble low-cost training kits based on the developmental age of the child, gave initial training in the basic behavioral technique to address the three autism symptom clusters at home. Follow-up support was given either on a weekly, fortnightly or monthly basis. Most of the children were also placed in play-schools. Data was analyzed using appropriate bivariate and multivariate techniques.ResultsThere was statistical and clinical amelioration in the severity of autism, with acquisition of social skills and language skills (all P = 0.001) after intervention in children with mild to severe autism. Gender showed a trend in becoming a significant predictor for intervention response.ConclusionsLow-intensity, home-based EI can be effectively used in situations where there is paucity of disability resources in countries like India, especially in primary-care and community settings.

Effectiveness of a Reproductive Sexual Health Education Package among School Going Adolescents

ObjectiveTo assess the effectiveness of a school based “Adolescent Reproductive Sexual Health Education (ARSHE) Package” in improving students’ knowledge on reproductive sexual health matters.MethodsAn ARSHE package originally developed at Child Development Centre, Kerala, modified and approved by ICMR taskforce group was administered in three urban schools (One boys only, one girls only and one co-education) and one co-education rural school at Thiruvananthapuram district, Kerala. The study sample consisted of 1,586 adolescents including 996 boys and 560 girls of class IX and XI. Pre and post intervention knowledge regarding reproductive sexual health matters was assessed using a self-administered questionnaire.ResultsIn the pre-intervention period, it was observed that majority of adolescents were poorly informed about reproductive sexual health matters, particularly about contraceptives. As compared to boys, girls had much poorer knowledge about prevention of pregnancy and after intervention; there was a statistically significant increase in the knowledge in both boys and girls. Among girls percentage of poor knowledge had reduced significantly from 64.1% to 8.3% and among boys from 37.7% to 3.5%. Similarly, increase in knowledge level was also observed in various other aspects of reproductive and sexual health including, STI, HIV/AIDS and perceptions about premarital sex.ConclusionsThe study results revealed the feasibility and effectiveness of school based reproductive and sexual health education intervention programs for adolescents.

INCLEN diagnostic tool for attention deficit hyperactivity disorder (INDT-ADHD): development and validation

ObjectiveTo develop and validate INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD).DesignDiagnostic test evaluation by cross sectional design. Setting: Tertiary care pediatric centers.Participants156 children aged 65–117 months.MethodsAfter randomization, INDT-ADHD and Connor’s 3 Parent Rating Scale (C3PS) were administered, followed by an expert evaluation by DSM-IV-TR diagnostic criteria.Main outcome measuresPsychometric evaluation of diagnostic accuracy, validity (construct, criterion and convergent) and internal consistency.ResultsINDT-ADHD had 18 items that quantified symptoms and impairment. Attention deficit hyperactivity disorder was identified in 57, 87 and 116 children by expert evaluation, INDT-ADHD and C3PS, respectively. Psychometric parameters of INDT-ADHD for differentiating attention deficit hyperactivity disorder and normal children were: sensitivity 87.7%, specificity 97.2%, positive predictive value 98.0% and negative predictive value 83.3%, whereas for differentiating from other neuro-developmental disorders were 87.7%, 42.9%, 58.1% and 79.4%, respectively. Internal consistency was 0.91. INDT-ADHD has a 4-factor structure explaining 60.4% of the variance. Convergent validity with Conner’s Parents Rating Scale was moderate (r =0.73, P= 0.001).ConclusionsINDT-ADHD is suitable for diagnosing attention deficit hyperactivity disorder in Indian children between the ages of 6 to 9 years.

ARSH 5: Reproductive health needs assessment of adolescents and young people (15-24 y): a qualitative study on 'perceptions of community stakeholders'.

ObjectiveTo explore the perceived reproductive health problems, health seeking behaviors, knowledge about available services and barriers to reach services among adolescents in order to improve reproductive health services for adolescents.MethodsThe study was conducted in three districts of Kerala and need assessment was done qualitatively using focus group discussions (FGDs), five each from all the three districts among junior public health nurses (JPHNs), anganwadi workers (AWWs), non-government organizations (NGOs), community leaders and adolescents.ResultsMajority of community stakeholders expressed that adolescents get knowledge regarding personal hygiene from their family itself and that they have poor knowledge about genital hygiene. Pain and associated problems are the most important difficulties faced by adolescent girls during menstrual periods. Most of the adolescents believed that excessive masturbation is a very dangerous practice. Most of the community stakeholders pointed out that though our adolescents know about HIV, they have very poor knowledge about other STIs and that parental ignorance increases vulnerability for sexual abuse among adolescents. They also suggested family life education sessions at schools and colleges for younger ones and premarital counseling for older ones, apart from counseling services and adolescent clinics. The important barriers in the utilization of services for adolescents are lack of awareness of parents, stigma to utilize services, economic factors, facility available at faraway places, and non-availability of services.ConclusionsThe need for adolescent friendly health services and premarital counseling services in the community attached to health facilities, has been highlighted.

A Panchayat Level Primary-care Approach for Adolescent Services

ObjectiveTo develop a model for providing community adolescent care services in the primary care settingMethodsNeed assessment was done among adolescents and perceived problems of adolescents were studied using qualitative and quantitative methods. Based on the results of these studies, a Family Life Education (FLE) module was prepared. Awareness programs were organized for all stakeholders in the community on adolescent issues. All anganwadi workers in the panchayat were trained to take interactive sessions for all the adolescents in the panchayat using the FLE module. Ward based Teen Clubs were formed in all the 13 wards of the Panchayat separately for boys and girls and FLE classes were given to them through anganwadi workers. An Adolescent Clinic was set up to provide necessary medical and counseling facilities. Adolescent Health Card was distributed to all Teen Club members and those who attended the adolescent clinics.ResultsThe present approach stresses the need and feasibility of adolescent-centered, community-based interventions. The authors’ experience showed that before starting any adolescent program, community awareness generation about the need and content of the program is very important for its success. The experience of this model has made it possible to up-scale the program to seven districts of southern Kerala as a service model.ConclusionsThe experiences of the program gave a realistic picture of the needs and problems of adolescents and a simple feasible model for providing services to adolescents in the primary care setting that can be easily replicated in other parts of India.

Priority Mental Health Disorders of Children and Adolescents in Primary-care Pediatric Setting in India 1: Developing a Child and Adolescent Mental Health Policy, Program, and Service Model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.

CDC Kerala 10: Diagnostic Accuracy of the Severity Scores for Childhood Autism Rating Scale in India

ObjectiveTo document the diagnostic accuracy of the Childhood Autism Scale (CARS) thresholds to identify mild, moderate and severe autism in India.MethodsThe CARS scores of 623 children, with and without autism were compared against the Diagnostic and Statistical Manual for Mental Disorders 4th edition (DSM-IV-TR) for ASD diagnosis and clinical consensus between two developmental paediatricians as the reference standard for autism severity using the Receiver operating characteristics (ROC) curve analyses and contingency tables.ResultsThe CARS total score for mild, moderate and severe autism ranged from 30.5 to 35, 35.5–40 and ≥40.5 respectively in this study. The overall diagnostic accuracy of CARS total score in the mild range was moderate [AUC = 0.68 (95%CI = 0.62–0.88), z = 1.34; P = 0.18], moderate range was high [AUC = 0.90 (95%CI = 0.77–0.97), z = 8.62; P = 0.0001] and severe range was also high [AUC = 0.85 (95%CI = 0.77–0.90), z = 7.09; P = 0.0001].ConclusionsThere are validated severity scores for Childhood Autism Rating Scale for clinical and research use in India.