1. PSYCHIATRIC PROFILE OF PEDIATRIC POPULATION PRESENTING TO A PSYCHIATRY CLINIC IN A TERTIARY CARE CENTRE Ajay Risal, Pushpa Prasad Sharma Department of Psychiatry, KUSMS Dhulikhel, Kavre, Nepal SAR- WONCA & GPAN Conference 2010

2. BACKGROUND WHO statistics shows the prevalence of disabling mental illnesses among children and adolescence attending health care centers ranging between 20-30% in urban and 13-18% in rural areas Hassan Z.K., 1991 2

3. Various studies from developing countries including Nepal and India show that a significant percentage (7-35%) of pediatric population suffers from mental illness Verghese et al, 1974; Shrestha DM, 1986; Chadda RK et al, 1994; Regmi SK et al, 2000; Pokharel A. et al, 2001; Malhotra S. et al, 2002; Srinath S et al, 2005; Mahat P et al, 2006; Shakya DR, 2010 3

4. PSYCHIATRIC DISORDERS IN PEDIATRIC POPULATION Disorders usually affecting adult, but also distressing in pediatric group like mood and anxiety disorders Disorders commonly diagnosed among child and adolescents like MR, SLD, ASD Other Disorders like Seizures and migraine 4

5. A great majority of children and adolescents visit other sources of help- seeking before coming to a psychiatric service for different psychological problems Regmi SK et al, 2000; Shakya DR, 2010 5

6. Mental and psychiatric services for children lag behind those for adults in developing countries Murray and Lopez, 1996 There is lack of specialized in-patient child psychiatry units Awareness regarding mental illnesses at community as well as at the level of health care providers is limited Sarwat A. et al, 2009 6

7. There are very few centers in Nepal which provide mental health services to children and adolescents We have extreme scarcity of child mental health resources and paucity of data related to child psychiatric illnesses Keeping this in mind, this study was carried out in our university hospital setting 7

8. AIMS & OBJECTIVES To study psychiatric manifestations in pediatric patients (below 18 years) presenting to a psychiatry clinic in a tertiary care hospital 8

9. MATERIALS AND METHODS I. Study Population: All the patients of pediatric age group (18 years and below) who were brought by their relatives to Psychiatry OPD of Dhulikhel Hospital directly or referred by pediatrician or other specialists from October 2008 to October 2010 (a period of 2 years duration) 9

10. II. Methodology: A retrospective file review was done from October 2008 to Mid-April 2010 (18 months) to get demographic details of such patients A prospective study was done from Mid- April 2010 to October 2010 (6 months)to analyze the psychiatric manifestations 10

11. III. Sample size Total (Oct08-Oct10)= 168 6 months prospective study (April10- Oct10)=80 11

12. IV. Procedure: Among the total patients studied for two years (N=168), demographic variables like age, sex and cast were analyzed Among the patients prospectively studied for six months(n=80), ICD-10 psychiatric diagnosis was analyzed in relation to the demographics, referral patterns and treatment related factors 12

13. V. Statistical Analysis: SPSS software package (Version 16, SPSS Inc., Chicago, USA) was used to analyze the data Descriptive statistics and Chi-square test was used to obtain the desired results 13

14. R ESULTS TABLE 1. DEMOGRAPHIC FINDINGS S.N. VARIABLES NUMBER (%) N=168 (100%) 1. AGE(YEARS) * 0 to 4years 2 (1.2) 5 to 9 years 9 (5.4) 10 to 14 years 45 (26.8) 15 to 18 years 112 (66.7) *Mean ( S.D.)= 14.77 ( 2.99) 14

15. S.N. VARIABLESNUMBER (%) N=168 (100%) 2.SEXMale 48 (28.6) Female 120 (71.4) 3.CAST/RACEBrahmin 71 (42.3) Chhetri 32 (19.0) Newar 28 (16.7) Mangolian 23 (13.7) Terai / Madhesi sub castes 1 (0.6) Dalit / Disadvantaged 13 (7.7) 15

16. FIG. 1. PEDIATRIC PATIENTS IN PSYCHIATRY CLINIC FROM OCT08-OCT10 16

17. TABLE 2. PSYCHIATRIC DIAGNOSIS (APRIL10- OCT10) S.N.PSYCHIATRIC DIAGNOSIS NUMBER (%) N=80 (100%) 1. ISH 11 (13.8) 2. Depression, Dysthymia and Adjustment Disorders 11 (13.8) 3. Dissociative/Conversion Disorder 12 (15.0) 4. Anxiety Disorder 5 (6.2) 5. Evolving Personality Disorder 2 (2.5) 6. Seizure Disorder 12 (15.0) 7. Headache Syndromes 7 (8.8) 8. Others 9 (11.2) 9. Not Recorded/ Undiagnosed 11 (13.8) 17

18. T ABLE 3. PSYCHIATRIC DIAGNOSIS AMONG DIFFERENT AGE GROUPS S.N. PSYCHIATRIC DIAGNOSIS AGE GROUP (YEARS)STATISTICS 0 -4 N 1 =1 (1.25%) 5-9 N 2 =3 (3.75%) 10-14 N 3 =22 (27.5%) 15 –18 N 4 =54 (67.5%) 2 df p-value 1. ISH 0(0.0%) 4(36.4%)7(63.6%) 17.389 24 0.832 2. Depression, Dysthymia and Adjustment Disorder 0(0.0%) 2(18.2%)9(81.8%) 3. Dissociative/Conversion Disorder 0(0.0%) 4(33.3%)8(66.7%) 4. Anxiety Disorder 0(0.0%) 1(20.0%)4(80.0%) 5. Evolving Personality Disorder 0(0.0%) 1(50.0%) 6. Seizure Disorder 0(0.0%) 3(25.0%)9(75.0%) 7. Headache Syndromes 0(0.0%)1(14.3%) 5(71.4%) 8. Others 1(11.1%) 2(22.2%)5(55.6%) 9. Not Recorded/ Undiagnosed 0(0.0%)1 (9.1%)4(36.4%)6(54.5%) 18

19. TABLE 4. PSYCHIATRIC DIAGNOSIS AMONG THE SEX GROUPS S.N.PSYCHIATRIC DIAGNOSIS SEXSTATISTICS MALE N 1 =23 (28.75%) FEMALE N 2 =57 (71.25%) 2 df p-value 1. ISH 1(4.3%)10(17.5%) 15.638 8 0.048 * *p-value <0.05 2.2. Depression, Dysthymia and Adjustment Disorder 7(30.4%)4(7.0%) 3. Dissociative/Conversion Disorder 1(4.3%)11(19.3%) 4. Anxiety Disorder 2(8.7%)3(5.3%) 5. Evolving Personality Disorder 1(4.3%)1(1.8%) 6. Seizure Disorder 1(4.3%)11(19.3%) 7. Headache Syndromes 2(8.7%)5(8.8%) 8. Others 4(17.4%)5(8.8%) 9. Not Recorded/ Undiagnosed 4(17.4%)7(12.3%) 19

20. T ABLE 5.PSYCHIATRIC DIAGNOSIS AMONG DIFFERENT CAST GROUPS S.N.PSYCHIATRIC DIAGNOSISCAST/RACESTATISTICS Brahmin N 1 =34 (42.5%) Chhetri N 2 =11 (13.75%) Newar N 3 =13 (16.25%) Mangolian N 4 =13 (16.25%) Dalit / Disadvantaged N 5 =9 (11.25%) 2 df p-value 1 ISH 3(8.8%)1(9.1%)3(23.1%) 1 (11.1%) 26.746 32 0.730 2. Depression, Dysthymia and Adjustment Disorder 4(11.8%)2(18.2%)2(15.4%) 1 (11.1%) 3. Dissociative/ Conversion Disorder 6(17.6%)2(18.2%)0 (0.0%)2(15.4%)2(22.2%) 4. Anxiety Disorder 2(5.9%)2(18.2%)1 (7.7%)0 (0.0%) 5. Evolving Personality Disorder 1(2.9%)0 (0.0%) 1 (11.1%) 6. Seizure Disorder 7(20.6%)1 (9.1%)2(15.4%) 0 (0.0%) 7. Headache Syndromes 6(17.6%)0 (0.0%) 1 (11.1%) 8. Others 2 (5.9%)2(18.2%)3(23.1%)1 (7.7%)1 (11.1%) 9. Not Recorded/ Undiagnosed 3(8.8%)1(9.1%)2(15.4%)3(23.1%)2(22.2%) 20

21. TABLE 6. PSYCHIATRIC DIAGNOSIS & REFERRAL CENTRES S.N. PSYCHIATRIC DIAGNOSIS REFERAL CENTERSSTATISTICS Pediatrics N 1 =35 (43.75%) Medicine N 2 =21 (26.25%) Emergency N 3 =6 (7.5%) Other Hospitals N 4 =4 (5%) Direct N 5 =14 (17.5%) 2 df p-value 1. ISH 4(11.4%)5(23.8%)2 (33.3%)0 (0.0%) 99.294 32 0.000*** p <0.001 2. Depression, Dysthymia and Adjustment Disorder 0 (0.0%)3(14.3%)0 (0.0%) 8 (57.1%) 3. Dissociative/ Conversion Disorder 8(22.9%)0 (0.0%)4 (66.7%)0 (0.0%) 4. Anxiety Disorder 0 (0.0%)3(14.3%)0 (0.0%)1 (25%)1 (7.1%) 5. Evolving Personality Disorder 0 (0.0%) 2 (14.3%) 6. Seizure Disorder 9 (25.7%)3(14.3%)0 (0.0%) 7. Headache Syndromes 5 (14.3%)2 (9.5%)0 (0.0%) 8. Others 1 (2.9%)2 (9.5%)0 (0.0%)3 (75%)3 (21.4%) 9. Not Recorded/ Undiagnosed 8(22.9%)3(14.3%)0 (0.0%) 21

22. T ABLE 7.PSYCHIATRIC DIAGNOSIS & OTHER PHYSICAL ILLNESSES S.N.PSYCHIATRIC DIAGNOSISPRESENCE OF PHYSICAL ILLNESSSTATISTICS YES N 1 =40 (50%) NO N 2 =40 (50%) 2 df p-value 1 ISH 3 (7.5%)8 (20%) 52.638 8 0.000*** ***p< 0.001 2. Depression, Dysthymia and Adjustment Disorder 2 (5.0%)9 (22.5%) 3. Dissociative/Conversion Disorder 0 (0.0%)12 (30%) 4. Anxiety Disorder 1 (2.5%)4 (10%) 5. Evolving Personality Disorder 0 (0.0%)2 (5.0%) 6. Seizure Disorder 12 (30%)0 (0.0%) 7. Headache Syndromes 7 (7.5%)0 (0.0%) 8. Others 4 (10%)5 (12.5%) 9. Not Recorded/ Undiagnosed 11(27.5%)0 (0.0%) 22

23. TABLE 8. PSYCHIATRIC DIAGNOSIS & MAGICORELIGIOUS TREATMENT S.N.PSYCHIATRIC DIAGNOSIS TREATMENT BY MAGICORELIGIOUS MEANS STATISTICS YES N 1 =12 (15%) NO N 2 =68 (85%) 2 df p-value 1 ISH 0 (0.0%) 11 (16.2%) 32.556 8 0.000*** ***p< 0.001 2. Depression, Dysthymia and Adjustment Disorder 0 (0.0%) 11 (16.2%) 3. Dissociative/Conversion Disorder 8 (66.7%)4 (5.9%) 4. Anxiety Disorder 0 (0.0%) 5 (7.4%) 5. Evolving Personality Disorder 0 (0.0%) 2 (2.9%) 6. Seizure Disorder 0 (0.0%) 12 (17.6%) 7. Headache Syndromes 1 (8.3%)6 (8.8%) 8. Others 1 (8.3%)8 (11.8%) 9. Not Recorded/ Undiagnosed 2(16.7%)9 (13.2%) 23

24. DISCUSSION Maximum patients (66.7%) were seen among the age group 15-18 yrs 71.4% of the pediatric population were female Similar findings were seen in a study among 100 pediatric patients in Dharan with predominance of age group 13-18 years (79%) and females ( 53%) Shakya DR, 2010 24

25. Female predominance was also seen in an Indian study by Prabhuswamy M. et al, 2006 while similar study by Chaudhury S et al, 2007 and Sarwat A. et al, 2009 showed male majority 25

26. Only 1.2% cases were found below four years of age in our study Similar findings were seen in the Chaudhury S et al, 2007 study Psychiatric structure before 4-5 years is usually not sufficiently developed to permit internal conflicts of pathological significance 26

27. The most common diagnosis (15%) was dissociative disorder equalizing to seizure It was followed by depression spectrum disorder and ISH (13.8% each) This was in accordance with the findings by Shakya DR, 2010 27

28. Diagnosis of Depression (30.4%) was maximum among males while dissociation (19.3%) was commonest among females which was statistically significant (p<0.05) 28

29. Clinic-based studies from different countries have reported high rates of dissociative disorders in the south Asian population* when compared to the studies done among western population** * Srinath S et al, 1993; Chandrasekaran R et al, 1994; Chaudhury S et al, 2007 ** Lehmkuhl GB et al, 1989; Tomasson K et al, 1991 29

30. Indian culture discourages direct expression of emotional distress Physical symptoms are a common way of expressing psychological distress Cross-cultural variation in rates of dissociative disorder Bhalla and Bhalla, 1986; Perera H. et al, 2004 30

31. We did not find specific child psychiatric illnesses like SLD, ADHD, ASD, MR as noted in other In-patient and Child Guidance Clinic Based studies by Perera H. et al, 2004; Sarwat A. et al, 2007; Chaudhury S. et al, 2007 Our sample pool was from a recently developing psychiatric unit dealing mainly with general psychiatric out-patients 31

32. Maximum (43.75%) referral was from pediatrics department, mainly for dissociative disorder (22.9%) which attained statistical significance (p<0.001) Similar findings were seen in various other studies (Perera H. et al, 2004; Chaudhury S et al, 2007) 32

33. This can be explained by the fact that most of the pediatric population visit other specialists, mainly pediatricians rather than directly coming to the psychiatric care as reported in the Shakya DR, 2010 study in BPKIHS 33

34. On evaluating the presence of other physical illnesses, maximum was seen in seizure disorder, while least physical findings were seen in patients with dissociative disorder attaining statistical significance (p<0.001) 34

35. 15% of the pediatric population were found to be treated by magico-religious means before coming to the hospital, most of them were having dissociative disorder (66.7%), which also showed statistical significance (p<0.001) 35

36. LIMITATIONS It is a hospital based study carried out on a sample size of <200 hence the results cannot be generalized Stigma, which may have a negative influence to psychiatric referral, was not studied Retrospective analysis of clinical records may have led inefficient data gathering Structured format to obtain parent feedback was not used 36

37. FUTURE DIRECTIONS Community based surveys should be carried out on larger scale to find out the depth of the psychiatric problems in children Appropriate sample size should be used Prospective analysis need to be encouraged Effect of stigma on psychiatric referral need to be studied Feedbacks from parents has to be studied using a structured format 37

38. ACKNOWLEDGEMENT: Mr. Seshananda Sanjel, MPH, Lecturer, KUSMS, Dhulikhel, Kavre, Nepal Patients of Dhulikhel Hospital THANK YOU!!!!!! 38