Naila Zaman Khan

The effects of a natural disaster on child behavior : evidence for posttraumatic stress

OBJECTIVES A prospective study of children examined both before and after a flood disaster in Bangladesh is used to test the hypothesis that stressful events play a causal role in the development of behavioral disorders in children. METHODS Six months before the disaster, structured measures of selected behavioral problems were made during an epidemiological study of disability among 2- to 9-year-old children. Five months after the disaster, a representative sample of 162 surviving children was reevaluated. RESULTS Between the pre- and postflood assessments, the prevalence of aggressive behavior increased from zero to nearly 10%, and 45 of the 134 children who had bladder control before the flood (34%) developed enuresis. CONCLUSIONS These results help define what may be considered symptoms of posttraumatic distress in childhood; they also contribute to mounting evidence of the need to develop and evaluate interventions aimed at ameliorating the behavioral and psychological consequences of childrens exposure to extreme and traumatic situations.

Behaviour problems in young children in rural Bangladesh.

OBJECTIVE To determine the prevalence of child behaviour problems reported by parents in rural Bangladesh. METHODS A total of 4,003 children aged 2-9 years were identified during a population-based survey of 2,231 households. A predetermined sample of 499 was selected, of which health professionals saw 453 (90.8%) for structured physical and neurological examination, standardized testing of cognition and adaptive behaviour and parent report of developmental history and behaviour problems. RESULTS The prevalence of behaviour impairments was 14.6% (95% CI 11.4, 17.9). The majority involved somatic complaints, including nocturnal enuresis and pica. Problems such as aggression or restlessness were infrequently reported. Behaviour impairments were significantly associated with malnutrition (prevalence ratio 2.1, 95% CI 1.2, 3.6, p < 0.01) and cognitive, motor or seizure disabilities (prevalence ratio 1.8, 95% CI 1.1, 2.9, p < 0.05). CONCLUSIONS The prevalence and nature of reported behaviour impairments in rural Bangladesh have implications for public health planning and delivery of health services.

Neurodevelopmental Sequelae in Pneumococcal Meningitis Cases in Bangladesh: A Comprehensive Follow-up Study

BACKGROUND Evaluation of the long-term impact of pneumococcal meningitis on surviving children and their families is critical to fully comprehending the burden of pneumococcal disease and to facilitating an evidence-based decision for the introduction of pneumococcal vaccine. This study was an investigation of the short- and long-term impacts of pneumococcal meningitis among Bangladeshi children. METHODS Case patients with pneumococcal meningitis who were hospitalized between January 2006 and March 2007 were subjected to short-term follow-up within 30-40 days of discharge. Case patients discharged prior to January 2005 were selected for long-term follow-up at 6-24 months after the date of discharge. Both cohorts were enrolled from Dhaka Shishu Hospital, a pediatric hospital in Bangladesh. Healthy children matched for age, sex, socioeconomic status, and area of residence were recruited from the community as control subjects. During follow-up visits, case patients and control subjects were assessed for their physical and neurodevelopmental status by use of a standardized protocol. The impact of pneumococcal meningitis on siblings and the family as a whole was assessed by means of qualitative interviews. RESULTS Neurodevelopmental assessments of the short-term follow-up cohort (n=51) revealed hearing, vision, mental, and psychomotor deficits in 33%, 8%, 41%, and 49% of the case patients, respectively. These deficits were 18%, 4%, 41%, and 35% in the long-term follow-up cohort (n=51), respectively. Such deficits were seen in only 2% of the control subjects, none of whom had vision or hearing deficits. CONCLUSIONS In addition to the risk of death, pneumococcal meningitis in children causes severe disabilities among survivors, as well as disruption of the life of other siblings and family members. This study demonstrated that high rates of sequelae are associated with pneumococcal meningitis. Neurodevelopmental assessment during follow-up of patients with meningitis is critical to our understanding of the burden of the adverse consequences of pneumococcal disease. These data, along with the fact of poor access to health care, provide a compelling argument in favor of the introduction of pneumococcal vaccine, specifically in a setting where access to health care is poor and disabled children remain incapacitated because of a lack of resources and facilities.

Stress in mothers of preterm infants in Bangladesh: associations with family, child and maternal factors and children's neuro-development

BACKGROUND The aim of this paper was to ascertain stress experienced by mothers of prospectively followed up preterm infants, and associations with family, child and maternal factors and childrens neuro-development. METHODS Within a follow-up study of preterm infants<33 weeks gestational age at a Child Development Center in Dhaka Shishu Hospital, mothers were interviewed with the Self-Report Questionnaire (SRQ) at each visit. Association between SRQ scores and child, family and maternal variables at first and final visit and childrens neuro-developmental outcomes was determined. RESULTS Low income mothers were more compliant (54%) compared with the defaulters (31%) (P=0.0001) among the 159 mothers enrolled. Of the 88 mothers who were followed up until a mean age of 22 months of their child, 29.3% were at high risk for psychiatric morbidity at first visit compared with 23.9% on their last visit. Use of abortifacients (P=0.026) and higher maternal age (P=0.040) were significantly associated with maternal stress at first visit; while at last follow-up, total number of visits had the most significant association (P=0.041). Twenty-five per cent and 19% of mothers were at risk for psychiatric morbidity in children developing normally and those with neuro-developmental impairments respectively. CONCLUSIONS Mothers at risk for psychiatric morbidity can be helped through follow-up support within public hospitals close to their homes, which is most availed by low income families. Neuro-developmental monitoring of high-risk infants closer to homes may be more feasible in resource poor countries than reliance on hospital visits, which increase stress. Biological markers of stress and coping strategies need further research.

Studies of children in developing countries. How soon can we prevent neurodisability in childhood

Neurodevelopmental disability is a functional limitation due to a neurological disorder with an onset early in life and occurs across a range of domains: cognition, movement, seizure disorders, vision, hearing, and behaviour. Disability can occur within a single domain or involve more than one domain in the case of multiple disabilities. Disabilities can be caused by a variety of etiological insults, many of which are preventable at a primary, secondary, or tertiary level. Neurodevelopmental disabilities are an important but largely unaddressed problem in low-income countries (Durkin et al. 1991). For this paper, the term ‘developing countries’ includes low-income countries with few professional and institutional health resources and inadequate infrastructure to deliver known effective preventive or rehabilitative measures nationally. It is understood that higher-income countries may also fail to address the challenges faced in preventing disability or in effective rehabilitation. Though many of the causes of neurodevelopmental disabilities in children in developing countries are identical to those in developed countries, there are causes which have an impact solely in developing countries such as cerebral malaria or trachoma. The prevalence of a disabilitywill increase or decrease in any given population depending on a variety of factors: for example, age distribution of the population, prevalence of the causal agents, availability of preventive measures or of initial treatment, and the longevity of those at risk. As a result, the epidemiology of neurodevelopmental disabilities show a markedly different pattern in developing countries than in the developed world.

Follow-Up of Cases of Haemophilus influenzae Type b Meningitis to Determine Its Long-Term Sequelae

OBJECTIVE To measure physical and neurologic impact of Haemophilus influenzae type b (Hib) meningitis on surviving children through short- and long-term follow-up. STUDY DESIGN Cases of Hib meningitis, diagnosed at a tertiary level pediatric hospital, were subjected to short- and long-term follow-up and compared with age, sex, and area of residence matched healthy controls. Follow-up assessments included thorough physical and neurodevelopmental assessments using a standardized protocol by a multidisciplinary team. RESULTS Assessments of short-term follow-up cohort (n = 64) revealed hearing, vision, mental, and psychomotor deficits in 7.8%, 3%, 20%, and 25% of the cases, respectively. Deficits were 10%, 1.4%, 21%, and 25% in long-term follow-up cohort (n = 71), in that order. Mental and psychomotor deficits were found in 2% of the controls, none of whom had vision or hearing deficits. CONCLUSIONS In addition to risk of death, Hib meningitis in children causes severe disabilities in survivors. These data facilitated a comprehensive understanding of the burden of Hib meningitis, specifically in developing countries where disabled children remain incapacitated because of lack of resources and facilities. The evidence generated from this study is expected to provide a compelling argument in favor of introduction and continuation of Hib conjugate vaccine in the national immunization program for children.

Community-based parent-delivered early detection and intervention programme for infants at high risk of cerebral palsy in a low-resource country (Learning through Everyday Activities with Parents (LEAP-CP): protocol for a randomised controlled trial

Introduction Cerebral palsy (CP) is the most common childhood physical disability, with 80% estimated to be in low-middle-income countries. This study aims to (1) determine the accuracy of General Movements (GMs)/Hammersmith Infant Neurological Examination (HINE) for detecting CP at 18 months corrected age (CA); (2) determine the effectiveness of a community-based parent-delivered early intervention for infants at high risk of CP in West Bengal, India (Learning through Everyday Activities with Parents for infants with CP; LEAP-CP). Methods This study comprises two substudies: (1) a study of the predictive validity of the GMs and HINE for detecting CP; (2) randomised, double-blinded controlled trial of a novel intervention delivered through peer trainers (Community Disability Workers, CDW) compared with health advice (15 fortnightly visits). 142 infants at high risk of CP (‘absent fidgety’ GMs; ‘high risk score’ on HINE) aged 12–40 weeks CA will be recruited to the intervention substudy, with infants randomised based on a computer-generated sequence. Researchers will be masked to group allocation, and caregivers and CDWs naïve to intervention status. Visits will include therapeutic modules (goal-directed active motor/cognitive strategies and LEAP-CP games) and parent education. Health advice is based on the Integrated Management of Childhood Illness, WHO. Infants will be evaluated at baseline, post intervention and 18 months CA. The primary hypothesis is that infants receiving LEAP-CP will have greater scaled scores on the Pediatric Evaluation of Disability Inventory—Computer Adaptive Test (mobility domain) at 18 months compared with health advice. Secondary outcomes include infant functional motor, cognitive, visual and communication development; infant growth; maternal mental health. Ethics and dissemination This study is approved through appropriate Australian and Indian ethics committees (see in text) with families providing written informed consent. Findings from this trial will be disseminated through peer-reviewed journal publications and conference presentations. Trial registration number 12616000653460p; Pre-results.