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Objective: There is no validated measure for assessing Attention Deficit Hyperactivity Disorder (ADHD) in India, and therefore, the authors validated the ADD-H Comprehensive Teacher's Rating Scale (ACTeRS). Methods: Teachers/parents/clinicians of 110 children with ADHD completed the ACTeRS. The diagnosis of ADHD was confirmed by an independent multi-disciplinary team using ICD-10 diagnosis for diagnostic accuracy and criterion validity. The convergent and divergent validity were assessed by another rater. The data was analyzed for diagnostic accuracy, reliability and validity appropriately. Results: An ACTeRS score of ≥61 [Sensitivity (Sn) =85.51 %; Specificity (Sp) = 90.24 %; Area under the curve (AUC) = 0.94] is appropriate for the diagnosis of ADHD. The test-re-test reliability [Intra-class correlation coefficient (ICC) = 0.87], internal consistency (Cronbach's α = 0.80; range of 0.89-0.93), section-total correlation, face and content validity for the ACTeRS were good. Convergent validity of attention deficit, hyperactivity and oppositional subscales of ACTeRS with the corresponding subscales of Swanson, Nolan & Pelham Rating Scale-Revised (SNAP-IV) was moderate ( r = 0.60, P = 0.005; r = 0.49, P = 0.02; r = 0.58, P = 0.008 respectively), and negative correlation with the Childhood Autism Rating Scale ( r = −0.36; P =0.1) for divergent validity was found. The criterion validity analysis showed a high concordance rate of 82.52 % between ACTeRS and International Classification of Diseases, Edition10 (ICD-10) diagnosis of ADHD. A 4-factor structure was replicated. Conclusions: The ACTeRS has adequate psychometric properties for use in the Indian population for identifying ADHD. [ABSTRACT FROM AUTHOR]

Objective: To determine the predictive factors associated with the adaptive behavior acquisition among children with Intellectual Disability (ID) in two different training packages. Methods: Parents of 52 consecutive children completed a demographic data form. Pre-intervention quantification of ID, parental attitude and adaptive behavior assessments were done using the Binet-Kamat Test of Intelligence or Gessells Developmental Schedule, Parental Attitude Scale towards Management of Intellectual Disability and Vineland Social Maturity Scale respectively, by independent raters. Univariate and multiple logistic regression models were used to identify the predictive models for the training outcomes and further validated using re-sampling technique. Results: Predictive factors associated with the good outcome in the multimodal adaptive behavior training plus interactive group psycho-education group were: younger age of the parent trained, and more than two siblings. Among the multimodal adaptive behavior training plus didactic lectures group, education of parent trained predicted better adaptive behavior interventional outcome. There was no association between the place of residence, socio-economic status, profession of parent, level of disability or the parental attitude. Conclusions: Different predictive factors are associated with potential short-term outcome of different adaptive behavior training for children with ID. Based on these pre-intervention predicators children and their parents can be given specific intervention packages. [ABSTRACT FROM AUTHOR]

Objective: To document the effectiveness of low intensity, clinic based intervention models for Autism Spectrum Disorders (ASD) in countries with low disability resources. Methods: Thirty-nine participants with a mean (SD) of 36.03(11.15) mo were assessed before and after intervention with Childhood Autism rating scale (CARS), and at baseline with the Denver Developmental Screening Test for quantifying the effectiveness of the clinic-based intervention in ameliorating autism symptoms and studying the effect of developmental disability respectively. Developmental therapists in the clinic gave low-intensity group intervention for 45-60 min to the child through mother and encouraged to continue the training, for 3-4 h, at home to address the specific goals in the three ASD symptom clusters. Most of the children were also placed in play-schools. Follow-up support was given either on a weekly, fortnightly or monthly basis. Data was analyzed using appropriate bivariate and multivariate techniques. Results: There was amelioration in the severity of autism after intervention, which was statistically and clinically significant. Intervention was useful to help children with mild to severe autism. Conclusions: Low-intensity, clinic-based intervention can be effectively used in situation where there is paucity of disability resources. [ABSTRACT FROM AUTHOR]

Objective: Autism Diagnostic Observation Schedule (ADOS) is considered gold standard for the diagnosis of Autism Spectrum Disorders (ASD). The authors evaluated the cumulative diagnostic accuracy of ADOS-Module 1 (ADOS) using the original diagnostic algorithm with meta-analysis and meta-regression. Methods: The authors, electronically and manually searched for studies from 1999 to 2013 that evaluated the accuracy of ADOS using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOS were summarized using random-effects model. Summary Receiver Operating characteristic Curves and its Area Under the Curve (SROC-AUC) were used to summarize overall diagnostic accuracy of ADOS. The modifying effects of quality of study and sample size, on the diagnostic odds ratio, were investigated using meta-regression. Results: A total of 7 cross-sectional studies provided data on 4,057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOS were: 0.91 (95 % CI = 0.88 to 0.93), 0.27 (95 % CI = 0.24 to 0.30), 5.40 (95 % CI = 1.51 to 19.23) and 0.52 respectively. Meta-regression analysis showed a non-significant relationship between ADOS and study quality as well as sample size. There were subgroup differences in the DOR. Conclusions: The authors conclude that ADOS with the original diagnostic algorithm lacks overall diagnostic accuracy and pooled specificity to confirm the diagnosis of Autism Spectrum Disorders. ADOS with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders. [ABSTRACT FROM AUTHOR]

Objective: To validate effectiveness of low intensity, home based early intervention (EI) models in autism for countries with low disability resources. Methods: Fifty-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. Results: There 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. Conclusions: Low-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. [ABSTRACT FROM AUTHOR]

Objective: Screen for Child Anxiety Related Emotional Disorders (SCARED), a measure found useful in different settings and cultures has not been validated in the subcontinent. This study validated this measure for identifying Anxiety Disorder (AD) among adolescents in an Indian community context. Methods: Five hundred adolescents were assessed with SCARED and DSM-IV-TR reference standard for diagnosis of AD. The interviewers were experienced raters who were further trained to interview participants using Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL). Sensitivity, specificity, likelihood ratios and predictive values for various SCARED cut-off scores were calculated. Test-retest reliability and inter-rater reliability of SCARED were examined. The dichotomized SCARED score was correlated with the DSM-IV-TR clinical diagnosis of AD to establish the criterion validity of SCARED as a measure of AD. Results: A SCARED total score of ≥21(Sn = 84.62 %, Sp = 87.36 %; AUC = 90 %) is suggested for diagnostic use in Indian population. Specific threshold scores were identified for the Panic Disorder, Generalized Anxiety Disorder, Separation Anxiety Disorder and Social Anxiety Disorder subscales. The inter-rater reliability (ICC = 0.87) and test-retest reliability (ICC = 0.90) for SCARED is good. Besides the adequate face and content validity, SCARED demonstrates good internal consistency (Cronbach's α = 0.89) and item-total correlation. There is a high concordance rate with the reference standard, DSM-IV-TR diagnosis [81 %; Cohen's κ = 0.42 (95 % CI = 0.31 to 0.52); P = 0.001] in classifying AD. Conclusions: SCARED has adequate psychometric properties and is now available for clinical and research work in India. [ABSTRACT FROM AUTHOR]

Objectives: Anxiety Disorders (AD) in children and adolescents present with unique clinical features and exhibit phenotypic diversity. The symptom presentation varies with regard to age of onset, developmental factors and gender. This study documents the clinical presentation of AD among adolescents in India, and explores the symptom clusters among the different age groups as well as gender. Methods: Five hundred adolescents aged between 11 and 19 y from Pattanakad ICDS block, of Allapuzha district in Kerala were recruited and assessed using the self-rated Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire to identify symptom clusters of anxiety and this was followed by confirmation of the diagnosis using DSM-IV TR within a week. Anxiety symptom clusters and severity (obtained from continuous SCARED scores) were compared between early, middle and late adolescence subgroups as well as between sexes. Results: The most predominant anxiety symptoms across the subtypes were the anxious mood, which was noted in 12.60 % followed by cognitive symptoms in 9.94 % of the cases and finally physical symptoms in 9.22 % of the study sample. The symptom clusters varied among the subtypes with anxious mood being commoner in Panic Disorder (PD), cognitive symptoms in Generalised Anxiety Disorder (GAD) and physical symptoms were prominent among Separation Anxiety (SeAD) and Social Anxiety Disorders (SoAD). The severity of anxiety disorder in general and its various subtypes were mostly of mild intensity although significant proportion had a severe form of the disease(s). The severity of the AD among girls was statistically significantly higher than boys ( P = 0.02). There was no significant difference on symptom frequency or anxiety severity with regard to age. Conclusions: Understanding of age appropriate presentation of anxiety symptoms may help in streamlining the treatment guidelines and yield a better estimate of the disease process. [ABSTRACT FROM AUTHOR]

Objectives: There is significant paucity of studies on the impairment associated with Anxiety Disorders (AD) among adolescents. This study focuses on the prevalence and pattern of impairment as well as impairment in the context of severity of AD, co-morbidities, suicide, age and gender in this population. Methods: In a prospective community survey of 500 adolescents, independent raters administered the Screen for Child Anxiety Related Emotional Disorders (SCARED) and Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime to collect the required data. Descriptive statistics and Chi-square tests were done to evaluate the prevalence and profile of impairment, compare the impairment among different types of AD, severity of AD, number of co-morbidities, age and gender on impairment, effect of impairment on the need for suicide prevention. Results: Impairment in adolescents with AD was a rule, noted in 94.4 %. Irrespective of the type of AD diagnosed, impairment at home was significant in adolescents with AD. The presentation of impairment among different Anxiety Disorders was different with different functional settings. Severity of AD and the number of co-morbidities was related to the impairment. Need for suicide related interventions were not different in those with and without impairment. Age and gender did not influence the presence of impairment. Conclusions: Anxiety Disorders among adolescents in India result in significant functional impairment. Clinically, in this population assessment of impairment is required. Community policies and plans should have special management strategy to address impairment in adolescents with Anxiety Disorders. [ABSTRACT FROM AUTHOR]

Objective: School Phobia (SP), although is not a formal psychiatric diagnosis, is widely prevalent debilitating phenomenon with a gamut of underlying psychiatric conditions in an overwhelming majority of cases. This study documents the prevalence, symptom presentation and the relationship between the various subtypes of Anxiety Disorders (AD) and School Phobia. Methods: In a prospective community survey of 500 adolescents, independent raters administered the Screen for Child Anxiety Related Emotional Disorders and Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime to identify SP and subtype of AD respectively. Descriptive statistics for the prevalence and symptom presentation, Spearman's Correlation test, Independent t tests, on-way ANOVA and Chi-square tests were done to compare the prevalence and severity of School Phobia among various age groups and gender. Univariate and multivariate analyses were done for documenting the relationship between the School Phobia and Anxiety Disorders. Results: School Phobia was noted in 4.8 % of adolescents. Although age was related to SP, gender, school grade the adolescent was attending and family structure were not related to SP. Somatic symptoms were more often noted than cognitive-emotional symptoms among adolescents with SP. Panic Disorder (OR = 8.62), Social Anxiety Disorder (OR = 8.63), and Separation Anxiety Disorder (OR = 6.26), were significantly related to SP. Conclusions: School Phobia is noted in a significant proportion of adolescents in the community. Anxiety Disorder is a major underlying factor resulting in SP. Community and clinical intervention and service models should include anxiety alleviation methods in adolescents with School Phobia. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The pediatrician is a primary column of support for children and adolescents with a myriad of mental health problems in low-mental health care resource countries like India. While majority of mental health consultations happen in primary-care, and only 10% are referred successfully for specialised help, there is a clear role for pediatrician psychotherapists in primary care. The primary-care pediatricians should be aware of the indications for psychotherapy, the various approaches that could be used in primary-care settings, the structure and the process of the psychotherapeutic technique involved, the suggested specific techniques for the Priority Mental Health Disorders and the evidence available to support their use as well as the developmental modifications that are required based on the cognitive development of the child or adolescent. [ABSTRACT FROM AUTHOR]

Objective: To compare the diagnostic accuracy of a self-rated and a clinician rated measure of depression for primary care use in school setting by pediatricians. Methods: Two tools for screening depression were administered to early adolescents in three schools. These included the self-rated Beck Depression Inventory (BDI), pediatrician rated Children's Depression Rating Scale-Revised (CDRS-R), and ICD-10 clinical interview by a psychiatrist as reference standard. These tools were compared for their overall performance using Areas Under the Curve (AUC) of Receiver Operating Characteristic (ROC) curves. The optimal screening threshold score for both tools were identified from their sensitivity and specificity plotted for all threshold scores. For the optimal cut-off scores, the diagnostic accuracy parameters like sensitivity, specificity, predictive values, likelihood ratio and diagnostic odds ratio were calculated using contingency table. Results: The area under the curve for BDI was 0.67 and CDRS was 0.50 suggesting that BDI as a screening tool has better diagnostic accuracy. The optimal screening threshold score for BDI was 18 with a sensitivity of 63 and specificity of 70. For the CDRS-R cut-off score of 59, the sensitivity was 36 and specificity was 82 respectively. Using both tools concurrently improved the diagnostic accuracy. Conclusions: Using the ROC characteristics and various validity indices, the authors showed that BDI has better sensitivity and CDRS-R a better specificity. It might be prudent to use both these instrument simultaneously to improve the identification of depression in primary care settings like school health clinic. [ABSTRACT FROM AUTHOR]

Objective: To compare the type of life events experienced and coping styles used by adolescents with and without psychopathology, attending a primary-care adolescent clinic. Methods: One hundred adolescents with and without psychopathology attending a drop-in adolescent clinic in a tertiary-care teaching hospital were recruited. Face-to-face interview used Child Behaviour Checklist, Life Event Scale, Coddington's life event scale, Impact of Event Scale and Modified Jalowiec coping scale as measures after getting written, informed consent from the primary care-giver and verbal assent from the adolescents. Bivariate and multivariate comparisons were done between the groups appropriately. Results: Adolescents with psychopathology had experienced more parental fights, increased arguments with parents, increased arguments between parents, serious illness requiring hospitalization of the adolescent. The intrusive symptoms of PTSD were noted more than avoidant symptoms among those adolescents with life events. Confrontative, emotive and optimistic coping styles were most often used in adolescent with psychopathology. Conclusions: In India, adolescents with psychopathology attending a primary care clinic have significant life events and different coping styles. Therefore, adolescents with psychopathology in this setting should be screened for life events as well as dysfunctional coping styles and given appropriate intervention. [ABSTRACT FROM AUTHOR]

Since there is no established measure for autism in India, we evaluated the diagnostic accuracy, reliability and validity of Childhood Autism Rating Scale (CARS). Children 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. A 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. The CARS has strong psychometric properties and is now available for clinical and research work in India. [ABSTRACT FROM AUTHOR]