Priya Mammen

Diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale in India

BackgroundSince there is no established measure for autism in India, we evaluated the diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale (CARS).MethodsChildren and adolescents suspected of having autism were identified from the unit’s database. Scale and item level scores of CARS were collected and analyzed. Sensitivity, specificity, likelihood ratios and predictive values for various CARS cut-off scores were calculated. Test-retest reliability and inter-rater reliability of CARS were examined. The dichotomized CARS score was correlated with the ICD-10 clinical diagnosis of autism to establish the criterion validity of CARS as a measure of autism. Convergent and divergent validity was calculated. The factor structure of CARS was demonstrated by principal components analysis.ResultsA CARS score of ≥33 (sensitivity = 81.4%, specificity = 78.6%; area under the curve = 81%) was suggested for diagnostic use in Indian populations. The inter-rater reliability (ICC=0.74) and test-retest reliability (ICC=0.81) for CARS were good. Besides the adequate face and content validity, CARS demonstrated good internal consistency (Cronbach’s α=0.79) and item-total correlation. There was moderate convergent validity with Binet-Kamat Test of Intelligence or Gessell’s Developmental Schedule (r=0.42; P=0.01), divergent validity (r=−0.18; P=0.4) with ADD-H Comprehensive Teacher Rating Scale, and high concordance rate with the reference standard, ICD-10 diagnosis (82.52%; Cohen’s κ=0.40, P=0.001) in classifying autism. A 5-factor structure explained 65.34% of variance.ConclusionThe CARS has strong psychometric properties and is now available for clinical and research work in India.

Predictive factors for polypharmacy among child and adolescent psychiatry inpatients

BackgroundAim was to determine the predictive factors for polypharmacy among inpatient children and adolescents with psychiatric disorders.MethodsBlinded, case-note review of children and adolescents with ICD 10 diagnosis of psychiatric disorders on psychotropic medication was conducted. Data on demography, illness, and treatment was analyzed with univariate and multivariate techniques.ResultsProscribing non-pharmacological interventions (OR = 4.7) and pro re nata medication (OR = 3.3), increased the risk of polypharmacy. Prescribing physical restraint reduced the risk of receiving multiple medications (OR = 0.3).ConclusionProscribing non-pharmacological interventions, pro re nata medication and physical restraints increased polypharmacy.

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.

Emerging trends in accepting the term intellectual disability in the world disability literature

English terminology thrives on words; words that are coined arbitrarily and often used idiosyncratically across time and space. In the past, some of the terms once used to describe individuals with compromised intellectual ability were not only acceptable (idiots: private person in Greek, imbecillis: weak and frail in Latin) but even honourable (cretins: Christian in Swiss-French), but are now used only as insults. As many of these old labels fade new ones evolve only to demonstrate that they themselves have a significantly short shelf-life. Whereas this editorial will argue that the term intellectual disability has universal consensus because of the manifold rationale discussed here. First, the debate as to whether the terminology or attitude should change in this context is an unsettled dispute. Terminologies are not neutral; they display the view of those who use it and indoctrinate those who hear it. This idea comes from an assumption that language is thought, and therefore when those with the disability have objected to these terms as reflections of the thoughts of others about them, such terms have to be discarded (Reid, 1997). Those who support a change in attitude, challenge that terms need not be thoughts, as we are often unable to translate some of our own thoughts into words. We solve problems manipulating mental images without using language and invent words for new ideas for which no words existed before, suggesting that it is our thoughts that contaminate our euphemisms, not the euphemisms that disinfect our thoughts (Crichton, 1997). In this polarized context the change in terminology to intellectual disability might be important in changing existing attitudes, and therefore may be widely appreciated by the professional community, e d i to r i a l

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.

Adolescent suicide: characterizing the need and identifying the predictive factors for preventive consultation or hospitalization in a rural community setting.

Abstract Background: Studies from India consistently document the highest suicide rates in the world, and the majority of completed suicides had been within adolescents. Objective: To characterize the need and identify the predictive factors for preventive consultation or hospitalization for adolescent suicide in a community setting. Subjects: We prospectively collected data from 500 adolescents in a rural South Indian community with independent, trained raters. Methods: The need for suicide prevention was measured with the SAD PERSONS scale, socio-economic status with the Modified Kuppusamy Scale, depression and anxiety disorders with the Beck Depression Inventory and the Screen for Child Anxiety Related Emotional Disorders, respectively. The relationship between predictors and the need for preventive action was analyzed with univariate and multivariate regression analyses and a predictive model was built. Results: Of those investigated, 2% and 0.6% required emergency consultation and hospitalization, respectively. Males needed more preventive action (p=0.04). Age (OR=3.40, p=0.07), gender (OR=3.13, p=0.05), presence of anxiety (OR=16.35, p=0.001), or depressive (OR=42.59, p=0.001) disorder independently predicted a need for protective action and, together, contributed to a parsimonious predictive model. Conclusions: The majority of adolescents in the community do not require preventive steps to address suicide risk. These predictors could identify the high-risk adolescents for suicide prevention and reduce the burden of care in the community.

Psychometrics and utility of Psycho-Educational Profile–Revised as a developmental quotient measure among children with the dual disability of intellectual disability and autism

There is no agreement about the measure to quantify the intellectual/developmental level in children with the dual disability of intellectual disability and autism. Therefore, we studied the psychometric properties and utility of Psycho-Educational Profile–Revised (PEP-R) as a developmental test in this population. We identified 116 children with dual disability from the day care and inpatient database of a specialised Autism Clinic. Scale and domain level scores of PEP-R were collected and analyzed. We examined the internal consistency, domain-total correlation of PEP-R and concurrent validity of PEP-R against Gesell’s Developmental Schedule, inter-rater and test–retest reliability and utility of PEP-R among children with dual disability in different ages, functional level and severity of autism. Besides the adequate face and content validity, PEP-R demonstrates a good internal consistency (Cronbach’s α ranging from 0.91 to 0.93) and domain-total correlation (ranging from 0.75 to 0.90). The inter-rater reliability (intraclass correlation coefficient, ICC = 0.96) and test–retest reliability (ICC = 0.87) for PEP-R is good. There is moderate-to-high concurrent validity with GDS (r ranging from 0.61 to 0.82; all Ps = 0.001). The utility of PEP-R as a developmental measure was good with infants, toddlers, pre-school and primary school children. The ability of PEP-R to measure the developmental age was good, irrespective of the severity of autism but was better with high-functioning children. The PEP-R as an intellectual/developmental test has strong psychometric properties in children with dual disability. It could be used in children with different age groups and severity of autism. PEP-R should be used with caution as a developmental test in children with dual disability who are low functioning.

Priority Mental Health Disorders of Children and Adolescents in Primary-care Pediatric Settings in India 2: Diagnosis, Pharmacological Treatment and Referral

The advent of pediatric psychopharmacology has enormously improved psychiatric care of children and adolescents. Nonetheless, our practice of diagnosis, treatment and referral in primary-care pediatric settings is not optimum as current evidence based knowledge is not regularly applied in the actual clinical circumstances. To help primary-care pediatricians minimise this in research-clinical practice, pharmacological treatment and referral in their clinical practice, they need to follow a two-tier diagnostic and multi axial treatment approach. The two-tier diagnostic approach of using a screening measure followed by confirmation of the screen positive cases with reference standard clinical criterion, improves the sensitivity and specificity. The multiaxial treatment has the advantage of offering a holistic approach to the intervention and improve prognosis from the interacting axes. The primary-care physician should be aware of the medications of choice for the Priority Mental Health Disorders and their drug interactions. Finally, referral of cases with atypical presentations, multiple comorbidities and poor response to the first-line of treatment needs referral to the next tier in the system.

Development and psychometric validation of the Brief Intellectual Disability Scale for use in low–health resource, high-burden countries

OBJECTIVE To develop and validate a concise, parent-completed Brief Intellectual Disability Scale (BIDS) for children in low-disability resource and high-disability care burden countries. STUDY DESIGN AND SETTING In this prospective cross-sectional study of 124 children recruited from a facility for intellectual disability (ID), the newly developed BIDS as the measure for validation as well as for the gold standard and convergent and divergent validities was administered by independent raters. Tests for diagnostic accuracy, reproducibility, and validity were conducted at the item and scale levels. RESULTS The BIDS scores of ≥5 (sensitivity [Sn] = 71.43%, specificity [Sp] = 80.95%) and ≥11 (Sn = 4.29%, Sp = 100%), with area under the curve of 0.79, are suggested, respectively, for screening and diagnostic use in Indian populations. The inter-rater reliability (intra-class correlation coefficient [ICC] = 0.96) and test-retest reliability at 4 weeks (ICC = 0.95) for BIDS are strong. Besides the adequate face and content validities, BIDS demonstrates good internal consistency (Cronbach α = 0.80) and item-total correlation. There is moderate convergent validity with Binet-Kamat Test of Intelligence or Gesells Developmental Schedule (r = -0.66, P = 0.001) as well as with adaptive behavior measure of Vineland Social Maturity Scale (r =-0.52, P = 0.001) and low divergent validity with the subscales of Attention Deficit Disorder with Hyperactivity: Comprehensive Teacher Rating Scale ( r = -0.11, P = 0.7; r = 0.18, P = 0.5; r = 0.13, P = 0.6; r = 0.08, P = 0.7). An exploratory factor analysis demonstrated a three-factor structure, explaining 60% of variance. CONCLUSION The BIDS shows promise as a psychometrically adequate, yet brief measure for identifying ID in countries with low disability care resources and high disability-related burden.