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Iron deficiency has become a common nutritional problem of developing countries, especially in children. This study approached to tackle the issue of iron deficiency by inexpensive fortified food such as chewing gums, which is commonly consumed by children. In this study, iron-fortified chewing gums were prepared by adding ferrous sulfate (FeSO4) and sodium iron EDTA (NaFeEDTA) 30 mg/100 g. An efficacy trial was conducted to determine the impact of iron-fortified chewing gums on the blood profile and iron status of school-going children (n = 300). Results showed maximum increase in blood profile and iron status that is, serum ferritin (10.43%), hemoglobin (3.22%), hematocrit (3.42%), red blood cells (3.05%), mean cell volume (1.55%), mean cell hemoglobin (5.43%), total white blood cells count (9.09%), and platelets count (4.40%) as compared with control whereas decrease in mean cell hemoglobin concentration (1.90%) and neutrophils (3.33%) was also observed. The study concluded that FeSO4 and NaFeEDTA (1:1) fortification of chewing gums is an appropriate approach for mitigating iron deficiency among the target population.

Background & Objective: Child & adolescent mental health needs to be considered as an integral component of overall health, however significant gaps exist in service provision especially inpatient services in Pakistan. The paper presents the characteristics of admitted youths and response to treatment in Pakistan’s first dedicated child & adolescent psychiatry inpatient unit in Lahore over a period of first seven years. The aim of this study was to better understand the various characteristics of children and youth admitted to this inpatient unit and response to treatment over a seven years’ period since the inception of the unit. Methods: Inpatient medical records of children & adolescents admitted to dedicated Child & Adolescent Inpatient Unit at King Edward Medical University, Lahore were reviewed. Data was extracted regarding referral patterns, sociodemographic factors and diagnosis for the first seven years, from 2012 to 2019. Patients’ scores on Strengths and Difficulties Questionnaire and Clinical Global Impressions Scales administered during intake were also reviewed. Results: Six hundred and thirty-four (634) patients, 56% (355) being females were admitted to the unit during seven years with mean age of 12.3±2.3. Mean duration of admission was 15.60±6.3 days. Most predominant ICD-10 Axis-I psychiatric diagnosis were neurotic, stress related and somatoform disorders (262); mood disorders (78); schizophrenia, schizotypal & delusional disorders (77) and behavioral and emotional disorders with onset usually occurring in childhood and adolescence (44). One hundred and fifty-nine (25%) children had comorbid diagnosis of intellectual disability on Axis-III. Strengths and difficulties questionnaire scores were in abnormal range for significant proportion (>50 %) of patients. CGI mean scores showed marked improvement at discharge. Conclusion: Neurotic, stress related and somatoform disorders are the most common diagnosis in youth needing inpatient treatment in Pakistani setup. Study results indicate that there is a clear need for specialized inpatient child and adolescent services such as ours in low- & middle-income countries. doi: https://doi.org/10.12669/pjms.37.2.2611 How to cite this:Imran N, Bodla ZH, Asif A, Shoukat R, Azeem MW. Pakistan’s First Child & Adolescent Psychiatry Inpatient Unit: Characteristics of admitted patients and response to treatment over a 7-year period. Pak J Med Sci. 2021;37(2):305-311. doi: https://doi.org/10.12669/pjms.37.2.2611 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

In this paper, we present a multi-region ensemble classifier approach (MRECA) using a cognitive ensemble of classifiers for accurate identification of attention-deficit/hyperactivity disorder (ADHD) subjects. This approach is developed using the features extracted from the structural MRIs of three different developing brain regions, viz., the amygdala, caudate, and hippocampus. For this study, the structural magnetic resonance imaging (sMRI) data provided by the ADHD-200 consortium has been used to identify the following three classes of ADHD, viz., ADHD-combined, ADHD-inattentive, and the TDC (typically developing control). From the sMRIs of the amygdala, caudate, and hippocampus regions of the brain from the ADHD-200 data, multiple feature sets were obtained using a feature-selecting genetic algorithm (FSGA), in a wraparound approach using an extreme learning machine (ELM) basic classifier. An improved crossover operator for the FSGA has been developed for obtaining higher accuracies compared with other existing crossover operators. From the multiple feature sets and the corresponding ELM classifiers, a classifier-selecting genetic algorithm (CSGA) has been developed to identify the top performing feature sets and their ELM classifiers. These classifiers are then combined using a risk-sensitive hinge loss function to form a risk-sensitive cognitive ensemble classifier resulting in a simultaneous multiclass classification of ADHD with higher accuracies. Performance evaluation of the multi-region ensemble classifier is presented under the following three scenarios, viz., region-based individual (best) classifier, region-based ensemble classifier, and finally a multiple-region-based ensemble classifier. The study results clearly indicate that the proposed “multi-region ensemble classification approach” (MRECA) achieves a much higher classification accuracy of ADHD data (normally a difficult problem because of the variations in the data) compared with other existing methods.

Autism is a fascinating topic that has attracted the interest of researchers and the lay public alike. The history of autism is filled with accomplishments of people who were astute observers of childhood psychopathology. Autism spectrum disorder affects a diverse group of children who share certain commonalities. There are ongoing attempts to understand its etiology and to refine diagnostic criteria for improved and timely recognition. In recent years, rapidly evolving research has highlighted the limits of our understanding of a disorder that at one time was considered rare, but now presents itself in 1 in every 59 children in the United States. This article particularly focuses on the history of autism as well as the changing criteria in the Diagnostic and Statistical Manual of Mental Disorders . [ Psychiatr Ann . 2019;49(3):103–108.]

Autism spectrum disorder (ASD) is a neurological and developmental disorder characterized by social impairment and restricted interactive and communicative behaviors. It may occur as an isolated disorder or in the context of other neurological, psychiatric, developmental, and genetic disorders. Due to rapid developments in genomics and imaging technologies, imaging genetics studies of ASD have evolved in the last few years. Increased risk for ASD diagnosis is found to be related to many specific single-nucleotide polymorphisms, and the study of genetic mechanisms and noninvasive imaging has opened various approaches that can help diagnose ASD at the nascent level. Identifying risk genes related to structural and functional changes in the brain of ASD patients provide a better understanding of the disease’s neuropsychiatry and can help identify targets for therapeutic intervention that could be useful for the clinical management of ASD patients.

Obsessive-compulsive disorder (OCD) can be found in about 4% of the general population and is characterized by various compulsions and obsessions that interfere with the person's quality of life from a mild to severe degree. The following discussion reflects on current concepts in this condition, including its epidemiology and etiologic underpinnings (behavioral, neurological, immunological, gastroenterological, as well as genetic). The interplay of PANS and PANDAS are included in this review. In addition, the core concepts of OCD diagnosis, differential diagnosis, and co-morbidities are considered. It is stressed that the quality of life for persons with pediatric OCD as well as for family members can be quite limited and challenged. Thus, principles of management are presented as a guide to improve the quality of life for these persons as much as possible.

Sources of data This article is based on key recent published literature including international guidelines and relevant reviews and meta-analyses. Authors have also supplemented this material with their own clinical experience. Areas of agreement There is an agreement that autism spectrum disorder (ASD) have a strong hereditary component. There is also a consensus that the reported prevalence estimates have increased in the last 5 years. There is strong support for using the broader spectrum disorder conceptualization of the DSM-5. Areas of controversy Higher public awareness of ASD has generated several controversial theories of causation. We review a number of environmental risk factors receiving media attention including: vaccines, mercury, heavy metal exposure and Selective Serotonin Uptake Inhibitors (SSRIs). Popular yet controversial treatment interventions are discussed. Early diagnostic screening tools are also addressed. Growing points There is increasing scientific interest in identifying biomarkers of autism with potential for early diagnosis, prognostic indicators and predictive treatment responses. We review evidence from genetics, neuroimaging and eye tracking as candidate biomarkers. Area timely for developing research Family studies point to a strong hereditary component in the aetiology of autism. However these studies have not established 100% concordance rates, suggesting a role for environmental factors. The gene-environment interplay has not received enough attention in scientific research. This represents an important new avenue for research in ASD.

Generalized anxiety disorder (GAD), despite being among the most common psychopathology of children and adolescents, often goes undetected and untreated. GAD is characterized by excessive worry for more than 6 months about a variety of situations, events, or activities (especially school performance among children), inability to control the worry, and presence of at least one physical symptom. The interplay of various risk factors (genetic, environmental, and psychosocial) and protective factors is seen in youth with GAD, and comorbidity is common. GAD is associated with significant distress and disability independent of comorbid disorders. A multimodal approach that includes psychoeducation, psychological therapies (in particular cognitive-behavioral therapy), family therapy, and pharmacological treatment provides the best outcome for children and adolescents with GAD. [ Psychiatr Ann. 2017;47(10):497–501.]

Autism spectrum disorder (ASD) is a genetic heterogeneous neurodevelopmental disorder that is characterized by impairments in social interaction and speech development and is accompanied by stereotypical behaviors such as body rocking, hand flapping, spinning objects, sniffing and restricted behaviors. The considerable significance of the genetics associated with autism has led to the identification of many risk genes for ASD used for the probing of ASD specificity and shared cognitive features over the past few decades. Identification of ASD risk genes helps to unravel various genetic variants and signaling pathways which are involved in ASD. This review highlights the role of ASD risk genes in gene transcription and translation regulation processes, as well as neuronal activity modulation, synaptic plasticity, disrupted key biological signaling pathways, and the novel candidate genes that play a significant role in the pathophysiology of ASD. The current emphasis on autism spectrum disorders has generated new opportunities in the field of neuroscience, and further advancements in the identification of different biomarkers, risk genes, and genetic pathways can help in the early diagnosis and development of new clinical and pharmacological treatments for ASD.

Objective: To measure the knowledge of healthcare professionals about increasingly prevalent Autism Spectrum Disorder (ASD) along with perceptions around its management and prognosis and comparison across various specialties. Methods: This Cross sectional survey based comparative analysis took place at Maternity and Children Hospital and King Faisal Hospital Makkah from December 2017 to May 2018. The validated self-administered “Knowledge about childhood autism among health workers” questionnaire was used along with additional questions regarding perceptions about ASD. The mean and mean percent scores were calculated. Chi squared test and ANOVA were applied to find the association between quantitative and qualitative variables respectively. Results: Out of 162 participants, 153 returned the questionnaire and 147 were included in final analysis. Physicians constituted 81.6% (120) of participants. The mean score for participants was 9.80(S.E.M ±0.32) where non-physicians yielded higher mean score (11.2±4.41) as compared to physicians (9.6±3.28) (p=0.113). Psychiatrists had highest score of 16/19 while general physicians had lowest (6/19). Participants with more years of experience had higher mean scores (p-value = 0.01). About 72.10% (106) of participants opted for medication as a treatment option. Nearly 38.1% (56) of participants were skeptical about improvement of ASD with early interventions. Conclusion: There is a lack of knowledge about ASD amongst healthcare professionals in Saudi Arabia. Experienced professionals working with ASD children can be utilized to deliver targeted trainings nationwide. doi: https://doi.org/10.12669/pjms.35.4.605 How to cite this:Hayat AA, Meny AH, Salahuddin N, Alnemary FM, Ahuja KR, Azeem MW. Assessment of knowledge about childhood autism spectrum disorder among healthcare workers in Makkah- Saudi Arabia. Pak J Med Sci. 2019;35(4):951-957. doi: https://doi.org/10.12669/pjms.35.4.605 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.

Background This study assessed anxiety and depression levels among parents of children with intellectual disability (ID) and analyzed their coping strategies. Methods One hundred parents of children with ID were recruited through child psychiatry outpatient services in a tertiary care setting in Lahore, Pakistan. A structured questionnaire including sociodemographic details, the Agha Khan University Anxiety Depression Scale, the Family Stress and Coping Questionnaire, Brief COPE questionnaire, and Support questionnaire were used for data collection. Results The mean age of parents was 35 years, and the majority of parents (86%) in the study were females. Seventy percent of the parents had significant levels of anxiety and depression. Parents mostly used emotion-based coping to deal with their anxiety and depression; self-distraction, behavioral disengagement, and venting were the main coping strategies used. Conclusions The study showed family stressors, various coping strategies, and support sources in depressed parents who are taking care of their intellectually disabled children. Based on these results, effective culturally sensitive intervention programs can be designed to educate parents and help them effectively cope with stress.

Autism spectrum disorder (ASD) is characterized by early-onset socialization and communication difficulties associated with restricted interests and behavioral rigidities. Recent epidemiologic studies show that 1 in 68 children has autism. This complex condition is among the least-understood developmental disorders of childhood but there is a growing body of research on ASD, making it critically important that clinicians are well informed about these conditions. Recent changes in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition, regarding ASD criteria can affect how the diagnosis is made. Various comorbidities can have a huge impact on assessment and management. There are various behavioral and pharmacologic strategies focusing on cluster symptoms of hyperactivity/inattention, irritability, aggression, self-injurious behaviors, and ritualistic behaviors. In the past few years, the US Food and Drug Administration has approved psychotropic medications for treating irritability associated with autism. Speech and language assessment and interventions, parent education, and appropriate educational programs are integral parts of management. [ Psychiatr Ann . 2016;46(1):58–62.]

Aims and methodTo assess adolescents' perceptions of their psychiatric illness and the role of various demographic factors in a Pakistani setting. Adolescents with various psychiatric diagnoses were interviewed using a structured questionnaire including the Illness Perceptions Questionnaire–Revised (IPQ-R).ResultsFifty-two adolescents with various psychiatric illnesses were interviewed; their mean age was 12.7 years and the majority (67%) were female. Males had significantly higher scores on timeline and emotional representation (PClinical implicationsDespite the importance of early intervention in psychiatric problems, engaging youth in the treatment process in Pakistan remains difficult. Better understanding of how adolescents perceive their psychiatric difficulties may play a significant role in developing culturally sensitive interventions and better utilisation of services.

N-acetylcysteine (NAC) is a well-known antidote for acetaminophen toxicity and is easily available over the counter. It has antioxidant and anti-inflammatory properties and an established tolerance and safety profile. Owing to its neuroprotective effects, its clinical use has recently expanded to include the treatment of different psychiatric and non-psychiatric disorders. Although a number of randomized controlled trials have documented the clinical evidence for NAC, there are no reviews that summarize the evidence. The present scoping review summarizes the study designs, the patient characteristics, the evidence and the limitations in randomized controlled trials designed to explore the efficacy of NAC for psychiatric conditions in the pediatric population.

Introduction Self-stigma has a negative impact on the lives of children with mental health illnesses. It is a massive obstacle in the way of seeking professional help and poses a challenge to clinician's efforts to timely intervene and provide treatment. Aim The aim of our study was to measure the stigma associated with mental illness in children with a variety of psychiatric diagnoses. Methods Following Institutional Review Board approval, an interviewer-based questionnaire was administered to children (aged 8–12 years), receiving treatment in Child Psychiatry Department at a tertiary care hospital in Lahore. The questionnaire comprised of Demographic Information Form and Paediatric Self-Stigmatization Scale (PaedS). In addition, parent / caregiver also completed a modified sub scale of the PaedS measuring the children’s rejection by others due to their mental health difficulties. Results 110 children with various psychiatric problems, were interviewed with a mean age of 10 years + 1.7. Widespread presence of self-stigmatization was found in these children with particularly high scores for the scales of Societal Devaluation (2.6 + 0.54), Secrecy (2.85 + 0.59) and Self stigma (2.7 + 0.70). Almost two third of parents also answered in affirmative to statements about their children rejection by others due to their mental health difficulties. Children with emotional/ behavioral difficulties had statistically significant scores on secrecy and personal rejection subscales (P value Conclusions Significant self-stigmatization amongst the children diagnosed with mental health illnesses in Lahore, Pakistan emphasize negative societal attitudes, which need to be addressed effectively in a timely manner.

OBJECTIVE: The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth. METHODS: The hospital staff received training in March 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 and March 2007. Data were collected on demographics, including age, gender, ethnicity, number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints. RESULTS: Four hundred fifty-eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy-nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints), with average number of episodes 3.5/patient (range 1–28). Thirty-seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%). CONCLUSIONS: This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health Program Directors six core strategies based on trauma informed care.

OBJECTIVE: Association between Intellectual disability (ID) and psychiatric disorders in children & adolescents is well established but there is a paucity of published studies from Pakistan on this topic. The main aim of the study was to assess the frequency of ICD-10 psychiatric diagnosis in the hospital outpatient sample of children with ID in Lahore, Pakistan as well as to find out which challenging behaviors, caregivers find difficult to manage in this setup. METHODS: Socio-demographic information was collected, Wechsler Intelligence Scale for Children-Revised & ICD-10 diagnostic criteria was used to assess children (age range 6 - 16 years) with suspected ID along with identification of behaviors found to be difficult to manage by caregivers. RESULTS: 150 children were assessed with mean age of 10.7 years (males 70 %). Majority (72%) had mild ID while 18.7% and 9.3% had moderate and severe ID respectively. Thirty percent of children met the criteria for any psychiatric diagnosis, the most common being Oppositional Defiant Disorder (14%) and Hyperkinetic Disorders (10%). Verbal and physical aggression, school difficulties, socialization problems, inappropriate behaviors (e.g. disinhibition), sleep & feeding difficulties were the significant areas identified by the caregivers as a cause of major concern. CONCLUSIONS: Significantly high prevalence of ICD-10 psychiatric diagnosis in children with ID was found in Lahore, Pakistan. Support services for these children should be responsive not only to the needs of the child, but also to the needs of the family. Language: en

article i nfo Keywords: Epilepsy Seizures ADHD Stimulant Methylphenidate Amphetamine Pharmacotherapy Comorbidity To retrospectively examine response to stimulant treatment in patients with epilepsy and ADHD symptoms as predicted by seizure freedom for six months, use of methylphenidate (MPH) versus amphetamine (AMP) preparations, cognitive level, and medical records were searched for patients under the age of 18 with epilepsy and ADHD symptoms treated with MPH or AMP (n = 36, age = 10.4 ± 3.5; male = 67%). "Responders" had a CGI-improvement score of ≤2 and did not stop medication because of adverse effects. "Worsened" patients discontinued medication because of agitation/emotional lability. Seizure freedom did not predict treatment response. Lower cognitive level was associated with increased rate of worsening (p = 0.048). No patients who were seizure-free at the start of the medication trial experienced an increase in seizures. Of the patients having seizures at the start of trial, one patient on MPH and two patients on AMP had increased seizures during the trial. Seizures returned to baseline frequency or less after stimulant discontinuation or anticon- vulsant adjustment. Methylphenidate was associated with a higher response rate, with 12 of 19 given MPH (0.62 ± 0.28 mg/kg/day) compared with 4 of 17 given AMP (0.37 ± 0.26 mg/kg/day) responding (p = 0.03). Methylphenidate treatment and higher cognitive level were associated with improved treatment outcome, while seizure freedom had no clear effect. Confidence in these findings is limited by the study's small, open-label, and uncontrolled design.

Background The diagnosis and treatment of Autism in Pakistan occurs in multiple settings and is provided by variety of health professionals. Unfortunately, knowledge and awareness about Autism is low among Pakistani healthcare professionals & the presence of inaccurate and outdated beliefs regarding this disorder may compromise early detection and timely referral for interventions. The study assessed the baseline knowledge and misconceptions regarding autism among healthcare professionals in Pakistan which can impact future awareness campaigns. Methods Physicians (psychiatrists, pediatricians, neurologists and family physicians) and non-physicians (psychologists and speech therapists) participated in this study. Knowledge of DSM-IV TR criteria for Autistic Disorder, beliefs about social, emotional, cognitive, treatment and prognosis of the disorder were assessed. Demographic information regarding the participants of the survey was also gathered. Results Two hundred and forty seven respondents (154 Physicians & 93 Non-physicians) participated in the study. Mean age of respondents was 33.2 years (S.D 11.63) with 53% being females. Reasonably accurate familiarity with the DSM IV-TR diagnostic criteria of Autistic Disorder was observed. However, within the professional groups, differences were found regarding the utilization of the DSM-IV-TR criteria when diagnosing Autistic Disorder. Non-Physicians were comparatively more likely to correctly identify diagnostic features of autism compared with Physicians (P-value Conclusion Results suggests that current professionals in the field have an unbalanced understanding of autism due to presence of several misconceptions regarding many of the salient features of autism including developmental, cognitive and emotional features. The study has clinical implications and calls for continued education for healthcare professionals across disciplines with regards to Autism in Pakistan.

Background Studies have shown higher rate of various psychiatric disorders among individuals with substance abuse / dependence. There is little data in developing countries, such as Pakistan, on prevalence of psychiatric co-morbidity in this population and impact on treatment. Objective To assess the psychiatric co-morbidity among individuals with substance dependence and to determine its demographic associations in patients with substance dependence in Pakistan. Method This was a descriptive study conducted at a tertiary care hospital in Pakistan. Participants were 588 individuals with substance dependence admitted to a tertiary care hospital in Pakistan, mainly in male inpatient substance dependence unit. The patients were assessed for psychiatric co-morbidity using DSM IV criteria. Informed consent was obtained. The study was approved by the Institutional Research Committee. The results were obtained by using chi square test on SPSS 17. Results Out of 588, 200 patients (34%) were found co-morbid with other psychiatric disorders along with substance dependence. Reason of first substance use and history of previous substance dependence were observed to be significantly associated with co-morbid psychiatric disorders, x2 (48, n = 549) = 112.396, p Conclusion 1. There was high rate of psychiatric co-morbidity among individuals with substance dependence in this sample. 2. Depression, personality disorders and anxiety disorders were the major co-morbid diagnosis among this population.