Child Psych

CHILD PSYCH FIRST DRAFT FINAL AND LAST ONE AND ITS EFFECTS ON CHILD 'S AND THEIR PARENTS ACCORDINGLY PATTERN OF CHILD PSCYHIATRY EMERGENCIES AND CONSULTS Global prevalence of mental disorders in Child and Adolescent (C&A) is about 20%. Approximately 85% of them reside in developing countries. There is an increase in presentation of C&A with mental health disorders to emergency department and as consultations from other departments. The aim of our study is to report pattern of referrals from emergency and other departments for C&A mental health problems.
TITLE PAGE:

PATTERN OF CHILD PSCYHIATRY EMERGENCIES AND CONSULTS

AUTHORS:

01. FAHEEM KHAN, FCPS (PSYCHIATRY), PGD (BIOETHICS). CONSULTANT PSYCHIATRIST AND SENIOR INSTRUCTOR, DEPT OF PSYCHIATRY, AGA KHAN UNIVERSITY HOSPITAL KARACHI. TEL NO: Tel No. 0092-21-3493 0051 Ext: 4694, faheemkhan.psychiatrist@gmail.com (corresponding author)

02. TAYYAB ARFEEN, TRAINING COMPLETED OF FELLOWSHIP, CONSULTANT PSYCHIATRIST AND INSTRUCTOR, DEPT OF PSYCHIATRY, AGA KHAN UNIVERSITY HOSPITAL KARACHI. TEL NO: Tel No. 0092-21-3493 0051 Ext: 4396, tayyab.arfeen@aku.edu

03. MUKESH BHIMANI, FCPS (PSYCHIATRY). CONSULTANT PSYCHIATRIST AND SENIOR INSTRUCTOR, DEPT OF PSYCHIATRY, AGA KHAN UNIVERSITY HOSPITAL KARACHI. TEL NO: Tel No. 0092-21-3493 0051 Ext: 4695, mukesh.bhimani@aku.edu

04. MOHAMMAD ZAMAN, MA (SOCIOLOGY), SENIOR RESEARCH OFFICER, DEPT OF PSYCHIATRY, AGA KHAN UNIVERSITY HOSPITAL KARACHI. TEL NO: Tel No. 0092-21-3493 0051 Ext: 4618, mohammad.zaman@aku.edu

05. TANIA NADEEM, DABPN, DABCAP, CONSULTANT PSYCHIATRIST AND ASSISTANT PROFESSOR, DEPT OF PSYCHIATRY, AGA KHAN UNIVERSITY HOSPITAL KARACHI. TEL NO: Tel No. 0092-21-3493 0051 Ext: 4691, tania.nadeem@aku.edu

ABSTRACT:

INTRODUCTION:

Global prevalence of mental disorders in Child and Adolescent (C&A) is about 20%. Approximately 85% of them reside in developing countries. There is an increase in presentation of C&A with mental health disorders to emergency department and as consultations from other departments. The aim of our study is to report pattern of referrals from emergency and other departments for C&A mental health problems.

METHOD:

We did a case note review of all cases below 18 years of age referred for mental health problems from Emergency and other departments of Aga Khan University hospital during June 2010 to December 2012. We extracted medical record numbers from consults. Data was entered and analyzed using SPSS 16. Chi square was used for categorical variables and t-test was applied for continuous variables. P value of less than 0.05 was taken as statistically significant. Exemption from research Ethics review committee was also taken.

RESULTS:

Among 160 consults generated during this time 90 were girls. Majority presented with Suicidal behavior (26%) followed by Behavioral symptoms (16.9%). Psychiatry team made a diagnosis of Mood disorder in 61 (38.8) cases followed by Conversion and adjustment disorders in 28 (17.5). Family conflict was the main stressor. In 43% of cases no Psychotropic was prescribed.

CONCLUSION:

C&A with mental health problems can presents with varying issues and stressors. Physicians who are expected to assess them at ED and other departments should be trained enough to identify common mental health problems. There is a need to develop effective consultation liaison services and community based research to ascertain burden of mental health problems in C&A in Pakistan.

INTRODUCTION:

Prevalence of mental health problems in Child and Adolescent (C&A) is on rise across the globe. At present prevalence is approximately 20%, of which around 4-6% is in need of clinical intervention.[i] Child and adolescent mental health service (CAMHS) is an essential component of a tertiary care hospital. Its domain ranges from outpatient & inpatient units, teaching to medical staff in contact with child and adolescent (C&A) and providing consultation liaison services across the hospital including emergency department. C&A presents in emergency department (ED) with an acute psychiatric disturbance or a crisis situation in a known psychiatric disorder.[ii] In addition to ED, different in-patients departments also seek consultation for mental health issues of C&A. According to research there is 110% of increase in C&A with mental health issues in ED and approximately 200,000 to over 825, 000 presents annually in USA to ED.[iii] This signifies the imperativeness of emergency care for C&A.

Multiple studies reports suicidal behavior as one of the most common presentation in ED. Depression, abuse, agitation, anxiety and Psychotic episodes are others with which C&A presents.[iv],[v],[vi],[vii] A study from Europe reports Substance abuse (21%) as the most common problem for referral from pediatrics ward followed by suicide attempts (17%), Eating disorder (15%), depression and adaptive disorders (both 8%).6

Developing countries lack resources to cater mental health problems in general. This problem becomes more pronounced as 85% of adolescents live in developing countries, thus more expected burden of mental health problem.[viii] Pakistan is a recourse poor developing country with an expected annual health budget of 7.8 billion[ix] and an expected population of 43% under 15 years of age.[x] A school based study done in Karachi reports prevalence of common mental disorder in age group between 5-11 years as 17%,[xi] highlighting the need to establish CAMHS. Trained personnel in C&A psychiatry is abysmally less in number (approximately 0.8% of all Psychiatrists in country) in Pakistan,[xii] risking a vast majority of population to sub-standard mental health services. Research in this important area is also scarce. Up to best of our knowledge there is no study from this region that reports pattern of referrals from ED and other departments. This present study is an attempt to bridge the research gap in this area of C&A mental health by reporting pattern of referral from ED and other departments of hospital.

METHODS:

This is a retrospective case-note review of all referrals generated by ED and other departments for mental health problems related to C&A at Aga Khan University Hospital (AKUH), Karachi. AKUH is a 500 bedded private tertiary care teaching hospital and is the only Joint Commission International Association (JCIA) accredited institute in the country.

We extracted medical records from electronic medical record system and included all files of C & A below 18 years of age, from June 2010 to December 2012. A data collection form was designed and piloted on first 10 files. Data was entered and analyzed using SPSS 16. Chi square was used for categorical variables and t-test was applied for continuous variables. P value of less than 0.05 was taken as statistically significant. Exemption from research Ethics review committee was also taken.

RESULTS:

160 consults were generated during study period (average 5.16 consults per month). Out of these, there were 70 boys (44%) and 90 girls (56%), giving a boys to girls ratio of 1.2:1, with mean age of 14.84 years (range 2-18 years). Mean age for boys was 15.1 (SD +- 3.27) and for girls was 14.6 (SD +_2.51). Most of the patients 46% (n=73) were in their secondary education (6-10th grade) followed by 16% (n=25) in Higher secondary education (11-13th grade), 14% (n=22) in primary education (1-5th grade) while data was missing in 21% of cases. Majority (66%) of referrals were from Emergency department followed by pediatrics (23%) and other in-patient units (11%). In 82% (n=131) of cases interviews were given by first degree relatives, only in 4% (n=6) of cases second degree relatives gave details.

Children and adolescents presented with varied symptoms: Suicidal behavior (26%), Behavioral symptoms (16.9%), Mood symptoms (13.8%), Physical symptoms (13.8%), Pseudo Neurological symptoms (13.8%) and Psychotic symptoms (6.3%) (Figure 01). Females were more likely to have a psychiatric illness than males (p-value 0.010) (Table 1). Mood disorders were the most common psychiatric disorders (n=61, 38.8%) of them 34% were having symptoms of Depressive and anxiety disorder, followed by conversion and adjustment disorders (n=28, 17.5%). In 21% (n=33) of the consults there was no diagnosable mental illness (Table 01). Major stressors identified were stress due to medical illness in 17% of cases followed by interpersonal conflicts, particularly within the family context or significant others (16%, n=26). No statistical difference in gender was found in type of stressors (p-value 0.54). (Table 02).

Out of 160 consults, 53% (n=85) were prescribed one of psychotropic, 4% (n=6) were prescribed medications other than psychotropic and no psychotropic was advised in 43% (n=69) of cases. Outpatient follow up was advised in 50% (n=80) of cases, while 25% (n=40) patients were transferred to psychiatric ward for further management.

DISCUSSION:

This study describes pattern of C&A referrals from ED and other wards of a tertiary care hospital in Pakistan. Referral rate in our study was less (05 consults per month) as compared to other studies (28 consults per month).13 This could be due to many factors; lack of awareness in parents about mental illnesses, stigma attached to such behaviors, psychiatric illnesses are generally less prioritize in ED setting and paying capacity of people since AKUH is private hospital.

This descriptive study found suicidal behavior (26%) as the most common presentation. This finding is similar to many studies: 11-25% of all referrals from ED,3,4 62.5% of total cases presented with deliberate self harm in ED from an inter-city sample of london,5 17% of total sample with suicide attempt referred from Pediatrics ward in a European hospital 6 and 20% with suicidal behavior from ED in a Australian hospital.[xiii] Another retrospective review from the same centre (AKUH) reported 69 cases of DSH presented in ED during the period 1990 to 2006 and concluded that an effective service should be developed for future referrals of such C&A.[xiv] Suicidal behavior is the most concerning behavior as it’s a terminal event and it also poses a challenge to health care professionals for proper assessment in short time. This also presses the need of developing more structured and flawless assessment. ED physicians and health care workers (like Pediatricians) dealing with C&A should receive structured training for suicide risk assessment.

In this study majority of the consults were from ED (66%) than Pediatrics ward (23%) and rest. This finding reflects a positive of ED physician doing better assessment however this also points toward increased responsibility of ED physicians in assessment and management of C&A with mental health issues.

This study found female child of having an increase risk of Psychiatric disorder. Evidence for gender specific burden of mental disorder is mixed, few suggests increase prevalence of mental disorder in male child, rest reports increase in female child especially in cases of DSH and depression. 5,6,11,13 Gender difference is important to know in youth since prevalence of some disorders remains high in females in later life also. We need to have more detail scientific evaluation of this phenomenon to know the hidden truth.

Among the Psychiatric disorders, depression and anxiety disorders (34%) were most common. This can also be correlated with prevalence of common mental disorder among adults in Pakistan and across the globe.[xv] Stressors are crucial as they not only cause but also perpetuate exiting illnesses. In young it becomes more pertinent as the expression could be variable from regression to aggression.[xvi] In our study stress because of suffering from medical illness (17%) and interpersonal conflicts (16%) were most common followed by Academic stress (13%). In a study by Syed & Khan, stressors related to school and home related were risk factors to suicide attempts.14

CONCLUSION:

Despite of small sample size this study does communicates a need to develop C&A mental health services. This study highlights the importance of suicidal behavior in C&A and the need to train health professionals for prompt and flawless assessment. There is need to identify risk factors for increased prevalence of mental health issues in female gender and to plan a national programme. This study also communicates a dire need to develop effective consultation liaison in tertiary care hospital for C&A. Keeping in view the dearth of trained C&A Psychiatrist in Pakistan, it seems relevant to propose structured training programme (fellowships) to bridge the gap. Lastly community based prevalence studies are needed to know the exact burden of illness in young cohort.

LIMITATIONS:

This was a retrospective review so the whole data collection was based on the available records only. In some cases patient got discharged before it was seen by Consultant Psychiatrist so we relied only on Residents note (but all cases were discussed with attending on phone). Sample size was small and from only one institute, are other limitations.

TABLE 01: PSYCHIATRIC DIAGNOSIS MADE BY PSYCHIATRY TEAM

|DIAGNOSIS |Males |Females |Total |P-value |
| |n(%) |n (%) |n (%) | |
|Mood Disorders (MDD, BAD (06 cases only), Anxiety) |27 (44.2) |34 (55.4) |61 (38.8) |0.010 |
|Conversion and Adjustment Disorder |6 (21.4) |22 (78.5) |28 (17.5) | |
|Psychosis (including Acute Psychotic episode and |8 (50) |8 (50) |16 (10 | |
|Schizophrenia) | | | | |
|Organic Disorder (Mental Retardation/Learning |3 (37.5) | 5 (62.5) |8 (5.1) | |
|Disability/ Delirium) | | | | |
|Others |6 (42.8) |8 (57.2) |14 (8.8) | |
|No Psychiatric Diagnosis |20 (60.6) |13 (39.3) |33 (20.6) | |
|TOTAL |70 (43.2) |90 (56.2) |160 (100) | |

*Based on DSM-IV TR

TABLE 02: STRESSORS IDENTIFIED IN PATIENTS

|STRESSORS |BOYS |GIRLS |TOTAL |P-VALUE |
| |n (%) |n (%) |N (%) | |
|Medical Problem |16 (57) |12 (42.8) |28 (17.5) |0.541 |
|Conflicts (family & others) |9 (34.6) |17 (65) |26 (16.2) | |
|Academic |10 (45.4) |12 (54.5) |22 (13.7) | |
|Others |7 (41) |10 (58.8) |17 (10.6) | |
|None |28 (41) |39 (58.8) |67 (41.8) | |
|TOTAL |70 (43.2) |90 (56.2 ) |160 (100) | |

FIGURE 01: PRESENTING SYMPTOMS ACCORDING TO GENDER

[pic]

Legend Key:

Psych Symp = Psychotic Symptoms, Mood Symp = Mood Symptoms, Anx Symptoms = Anxiety symptoms, Beh Symp = Behavioral Symptoms, Psud Neuro Symp = Psuedo Neurological Symptoms, Phys symp = physical symptoms

REFERENCES:

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[i] Hresources ML, Ure I. Atlas. 2005. , {Atlas child and adolescent mental health resources global concerns : implications for the future, available from http://www.who.int/mental_health/resources/Child_ado_atlas.pdf ACCESSED ON March 5, 2013}

[ii] Carandang C, Gray C, Marval-Ospino H, MacPhee S. Child and adolescent psychiatric emergencies. In ReyJM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

[iii] Cooper JL, Masi R. Child and youth emergency mental health care: A national problem. 2007.

[iv] Margulies DM, Carlson GA. Assessment of Child and Adolescent Psychiatric Emergencies. Child and Adolescent Psychopharmacology News.17(1):1-4.

[v] Healy E, Saha S, Subotsky F, Fombonne E. Emergency presentations to an inner-city adolescent psychiatric service. Journal of Adolescence. 2002;25(4):397-404.

[vi] Wiśniewski A, Niwiński P, Tywonek M, Langowicz I. P-416-Psychiatric consultation on pediatric wards: four-year report and a proposition of new application form. European Psychiatry.27:1.

[vii] Jacintho AÃ, Santos A, Salán TM, Celeri E, Banzato CEM, Dalgalarrondo P. P02-11-Psychiatric emergencies in children: demographic and clinical care in a university hospital. European Psychiatry.25:629.

[viii] The state of the world 's children 2000. [homepage on the Internet]. 2011 [cited 2013 Mar 5]. Available from: UNICEF, Web site: http://www.unicef.org/sowc00/map1.htm

[ix] Federal Budget 2012-2013, [homepage on the Internet]. 2012 [cited 2013 Mar 5]. Available from: Government of Pakistan, Finance Division, Islamabad, Web site: http://www.finance.gov.pk/budget/Budget_in_Brief_2012_13.pdf

[x] Country Cooperation Strategy at a Glance, [homepage on the Internet]. 2011 [cited 2013 Mar 5]. Available from: World Health Organisation, Web site: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_pak_en.pdf

[xi] Syed EU, Hussein SA, Haidry S-e-Z. Prevalence of emotional and behavioural problems among primary school children in Karachi, Pakistanâ”multi informant survey. Indian journal of pediatrics. 2009;76(6):623-7.

[xii] Atlas: child, adolescent and maternal mental health resources in the Eastern Mediterranean Region: / World Health Organization. Regional Office for the Eastern Mediterranean. (EMRO Technical Publications Series No; 39)

[xiii] Jean S, Kim B, Donna R. Psychiatric emergencies in children and adolescents: an Emergency Department audit. Australasian Psychiatry. 2006;14(4):403-7.

[xiv] Syed EU, Khan MM. Pattern of deliberate self-harm in young people in Karachi, Pakistan. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2008;29(3):159-63.

[xv] Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. Bmj. 2004;328(7443):794.

[xvi] Identifying signs of stress in your children and teens, [homepage on the Internet]. 2013 [cited 2013 Mar 5]. Available from:, American Psychological Association Web site: http://www.apa.org/helpcenter/stress-children.aspx

LIST OF ABBREVIATIONS:

AKUH: Aga Khan University Hospital

C&A: Child and Adolescent

CAMHS: Child and adolescent mental health services

ED: Emergency department

COMPETING INTERESTS AND DISCLOSURE:

We declare that none of the authors have any financial or non-financial competing interests.

Findings of this paper were presented in 03rd Annual Emergency Medicine Conference, Emergency care for Children at Aga Khan University Hospital, Karachi on March 16, 2013.

AUTHORS CONTRIBUTION:

FK TA & TN conceived the idea

FK,TA & MB developed the protocol

TA, MZ & MB collected the data

MZ carried out data entry

FK,MB, MZ & TN carried out the analyses and drafted article

All authors reviewed the manuscript critically and approved it

ACKNOWLEDGMENT:

Dr Murad Moosa Khan, MRCPsych, Professor and chair Dept of Psychiatry, Aga Khan University Hospital for guidance, draft editing and encouragement throughout the process.

References: [iii] Cooper JL, Masi R. Child and youth emergency mental health care: A national problem. 2007. [v] Healy E, Saha S, Subotsky F, Fombonne E. Emergency presentations to an inner-city adolescent psychiatric service. Journal of Adolescence. 2002;25(4):397-404. [viii] The state of the world 's children 2000. [homepage on the Internet]. 2011 [cited 2013 Mar 5]. Available from: UNICEF, Web site: http://www.unicef.org/sowc00/map1.htm [ix] Federal Budget 2012-2013, [homepage on the Internet] [xiv] Syed EU, Khan MM. Pattern of deliberate self-harm in young people in Karachi, Pakistan. Crisis: The Journal of Crisis Intervention and Suicide Prevention. 2008;29(3):159-63. [xv] Mirza I, Jenkins R. Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. Bmj. 2004;328(7443):794. [xvi] Identifying signs of stress in your children and teens, [homepage on the Internet]. 2013 [cited 2013 Mar 5]. Available from:, American Psychological Association Web site: http://www.apa.org/helpcenter/stress-children.aspx LIST OF ABBREVIATIONS: Findings of this paper were presented in 03rd Annual Emergency Medicine Conference, Emergency care for Children at Aga Khan University Hospital, Karachi on March 16, 2013.