Prevalence of intellectual disability in India: A meta-analysis.

BACKGROUND: Burden due to intellectual disability (ID) is only third to the depressive disorders and anxiety disorders in India. This national burden significantly contributes to the global burden of ID and hence one has to think globally and act locally to reduce this burden. At its best the collective prevalence of ID is in the form of narrative reviews. There is an urgent need to document the summary prevalence of ID to enhance further policymaking, national programs and resource allocation. AIM: To establish the summary prevalence of ID during the past 60 years in India. METHODS: Two researchers independently and electronically searched PubMed, Scopus, and the Cochrane library from January 1961 to December 2020 using appropriate search terms. Two other investigators extracted the study design, setting, participant characteristics, and measures used to identify ID. Two other researchers appraised the quality of the studies using the Joanna Briggs Institute critical appraisal format for Prevalence Studies. Funnel plot and Egger's regression test were used to ascertain the publication and small study effect on the prevalence. To evaluate the summary prevalence of ID, we used the random effects model with arcsine square-root transformation. Heterogeneity of I 2 ≥ 50% was considered substantial and we determined the heterogeneity with meta-regression. The analyses were performed using STATA (version 16). RESULTS: Nineteen studies were included in the meta-analysis. There was publication bias; the trim-and-fill method was used to further ascertain bias. Concerns with control of confounders and the reliable measure of outcome were noted in the critical appraisal. The summary prevalence of ID was 2% [(95%CI: 2%, 3%); I 2 = 98%] and the adjusted summary prevalence was 1.4%. Meta-regression demonstrated that age of the participants was statistically significantly related to the prevalence; other factors did not influence the prevalence or heterogeneity. CONCLUSION: The summary prevalence of ID in India was established to be 2% taking into consideration the individual prevalence studies over the last six decades. This knowledge should improve the existing disability and mental health policies, national programs and service delivery to reduce the national and global burden associated with ID.

Pediatric Anesthesia Emergence Delirium Scale: A diagnostic meta-analysis.

BACKGROUND: Emergence delirium (EmD) is a troublesome motoric, emotional, and cognitive disturbance associated with morbidity. It is often misdiagnosed despite being present in a substantial proportion of children and adolescents during emergence from anesthesia. AIM: To evaluate the summary diagnostic accuracy of Pediatric Anesthesia Emergence Delirium Scale (PAEDS) for EmD among children and adolescents. METHODS: Two researchers electronically and hand searched the published literature from May 2004 to February 2021 that evaluated the diagnostic accuracy of PAEDS for EmD among children and adolescents, using appropriate terms. Two independent researchers extracted the diagnostic parameters and appraised the study quality with QUADAS-2. Overall, the diagnostic accuracy of the measures was calculated with the summary receiver operating characteristic curve (SROC), the summary sensitivity and specificity, and diagnostic odds ratio (DOR) for EmD. Various diagnostic cut-off points were evaluated for their diagnostic accuracy. Heterogeneity was analyzed by meta-regression. RESULTS: Nine diagnostic accuracy studies of EmD that conformed to our selection criteria and PRISMA guidelines were included in the final analysis. There was no publication bias. The area under the SROC was 0.97 (95% confidence interval [CI]: 95%-98%). Summary sensitivity and specificity were 0.91 (95%CI: 0.81-0.96; I 2 = 92.93%) and 0.94 (95%CI: 0.89-0.97; I 2 = 87.44%), respectively. The summary DOR was 148.33 (95%CI: 48.32-455.32). The effect size for the subgroup analysis of PAEDS cut-off scores of < 10, ≥ 10, and ≥ 12 was 3.73, 2.19, and 2.93, respectively; they were not statistically significantly different. The setting of the study and reference standard were statistically significantly related to the sensitivity of PAEDS but not specificity. CONCLUSION: The PAEDS is an accurate diagnostic measure for the diagnosis of EmD among children and adolescents. Further studies should document its clinical utility.

Diagnostic accuracy and clinical utility of non-English versions of Edinburgh Post-Natal Depression Scale for screening post-natal depression in India: A meta-analysis.

BACKGROUND: The prevalence of post-natal depression (PND) is high in India, as it is in many other low to middle income countries. There is an urgent need to identify PND and treat the mother as early as possible. Among the many paper and pencil tests available to identify PND, the Edinburgh Postnatal Depression Scale (EPDS) is a widely used and validated measure in India. However, the summary diagnostic accuracy and clinical utility data are not available for this measure. AIM: To establish summary data for the global diagnostic accuracy parameter as well as the clinical utility of the non-English versions of the EPDS in India. METHODS: Two researchers independently searched the PubMed, EMBASE, MEDKNOW and IndMED databases for published papers, governmental publications, conference proceedings and grey literature from 2000-2018. Seven studies that evaluated the diagnostic accuracy of EPDS in five Indian languages against DSM/ICD were included in the final analysis. Two other investigators extracted the Participants' details, Index measures, Comparative reference measures, and Outcomes of diagnostic accuracy data, and appraised the study quality using QUADS-2. Deek's plots were used to evaluate publication bias. We used the area under the curve of the hierarchical summary area under the receiver operating characteristic curve, with the random effect model, to summarize the global diagnostic accuracy of EPDS. Using the 2 × 2 table, we calculated positive and negative likelihood ratios. From the likelihood ratios, the Fagan's nomogram was built for evaluating clinical utility using the Bayesian approach. We calculated the 95% confidence interval (95%CI) whenever indicated. STATA (version 15) with MIDAS and METANDI modules were used. RESULTS: There was no publication bias. The area under the curve for EPDS was 0.97 (95%CI: 0.95-0.98). The pre-test probability for the nomogram was 22%. For a positive likelihood ratio of 9, the positive post-test probability was 72% (95%CI: 68%, 76%) and for a negative LR of 0.08, the negative post-test probability was 2% (95%CI: 1%, 3%). CONCLUSION: In this meta-analysis, we established the summary global diagnostic parameter and clinical utility of the non-English versions of the EPDS in India. This work demonstrates that these non-English versions are accurate in their diagnosis of PND and can help clinicians in their diagnostic reasoning.

The clinical usefulness of three depression screens for adolescents in India: A need in primary-care settings.

INTRODUCTION: Adolescent Depression (AD) although is widely prevalent and is a prioritized disorder, it is under-diagnosed and under reported in primary-care. We document the post-test probability of three measures and select the best measure for identifying AD in primary-care settings in India based on the clinical utility. MATERIALS AND METHODS: Three measures have been validated in India for AD and thus can be further evaluated for primary-care use; we calculated the positive (+PTP) and negative (-PTP) post-test probability from the prevalence of AD in India for Beck Depression Inventory-21 item version (BDI-21), Patient Health Questionnaire-9 item version (PHQ-9), and Children's Depression Rating Scale-Revised version (CDRS-R) using the Bayes theorem. The usefulness of the measure was defined a priori based on the odds ratio (OR) of +PTP (OR > 3) and -PTP (OR < 0.1). RESULTS: The +PTP and -PTP for BDI-21 was 43% (95%CI = 40, 45%; OR = 0.7) and 25% (95%CI = 13, 43%; OR = 0.3) respectively. Similarly, the +PTP and - PTP for PHQ-9 was 74% (95%CI = 66, 81%; OR = 2.9) and 10% (95%CI = 6, 17%; OR = 0.1). Finally, +PTP and - PTP for CDRS-R was 78% (95%CI = 69, 84%; OR = 3.5) and 12% (95%CI = 7, 18%; OR = 0.1). Only CDRS-R achieved the useful decided a priori as can be seen in the Fagan's Nomograms. CONCLUSION: This research provides the evidence base for selecting CDRS-R as the screening measure, for Adolescent Depression, for clinical use in Primary-care settings in India.

Dysfunction among Families of Children with Intellectual Disability in India Using Systems Model: Prevalence, Pattern, and Severity of Impairment.

OBJECTIVES: Family dysfunction is observed in families with children with intellectual disability (ID). We study the prevalence, pattern of dysfunction, and severity of impairment in these special families using Systems approach. METHODS: Sixty-two special families (a child with ID) and 62 typical families (all children with typical development) were included in the present study. The presence of ID was confirmed and quantified with the Binet-Kamat Scale of intelligence or Gesell's Developmental Schedule and Vineland Social Maturity Scales among the special families. In the typical families, brief ID scale was used to rule out ID. Prevalence, pattern, and severity of family dysfunction were assessed using Family Apgar Scale, Chicago Youth Development Study Family Assessment Scale and Global Assessment of Relational Functioning Scale, respectively. Appropriate bivariate analyses were used. RESULTS: About 53% of special families and 19% of typical families had family dysfunction. About 21% of special families and 71% of typical families had the satisfactory relational unit. Areas of adaptability, partnership, growth, affection, resolve, beliefs about family, beliefs about development, beliefs about purpose, cohesion, deviant beliefs, support, organization, and communication were significantly different between special and typical families. The functional impairment was significantly more in the special families. CONCLUSION: Family dysfunction is more prevalent among special families in India using systems approach. These families should be screened for dysfunction, and family therapy be prescribed when required.

The Confirmatory Factor Analysis of the Original Brief Intellectual Disability Scale and Alternative Models.

OBJECTIVE: Brief Intellectual Disability Scale (BIDS) is a measure validated for identification of children with intellectual disabilities (IDs) in countries with low disability resources. Following the publication of the exploratory factor analysis of BIDS, the authors have documented the confirmatory factor analysis (CFA) of BIDS in this study. MATERIALS AND METHODS: A prospective cross-sectional study was conducted to document the CFA of the BIDS. Primary caregivers (N = 124) of children with ID were recruited and rated the BIDS. We used alternative fit indices for the evaluation of comparative fit index (CFI) and root mean square error of approximation (RMSEA) to evaluate the model fit. The 2-index fit strategy was used to select the best factor model. RESULTS: The model fit index for the original 3-factor model and alternative 2-factor and 1-factor models with 9 items of the BIDS was under identified along with another 3-factor, 7-item model. Another 1-factor, 7-item model was identified but did not satisfy the 2-index fit strategy. A short version of the scale with a 2-factor and 7-item model of BIDS presented the best fit indices of CFI = 0.952 and RMSEA = 0.069. CONCLUSION: Although the original factor structure of BIDS was not confirmed in this study, another alternative a priori model for the construct validity of BIDS was confirmed. Therefore, the BIDS factor structure has been revised, refined, and trimmed to the final 2-factor, 7-item shorter version. Further documentation of the diagnostic accuracy, validity, and reliability of this shorter version of BDI is recommended.

Comparison of the Diagnostic Accuracy and Validity of a Short Version of Teen Screen Questionnaire-Mental Health (TSQ -M-Short) for Use in Community.

BACKGROUND: A few self-administered questionnaires are available for assessing mental health among adolescents in primary-care settings. Brief measures are desirable for use in big-data, epidemiological studies. OBJECTIVES: To evaluate a 7-item version, of the Teen Screen Questionnaire-Mental Health (TSQ-M), the TSQ-M-Short. MATERIALS AND METHODS: In this prospective cross-sectional study of 140 adolescents, recruited from 6 rural or urban schools, the newly developed TSQ-M-Short as the measure for validation and General Health Questionnaire-12 item (GHQ-12) as the gold standard measure were administered by independent trained raters. Tests for diagnostic accuracy and validity were conducted. RESULTS: A total TSQ-M-Short score of ≥ 6 had a sensitivity of 76%, specificity of 74%, positive likelihood ratio of 2.99, negative likelihood ratio of 0.33, positive predictive value of 6% and a negative predictive value of 82.1%. The area under curve (AUC) in the Receiver Operating Characteristic (ROC) for the TSQ-M-Short version was 0.84 (95% cumulative incidence (CI) = 0.76-0.89). The AUC for the TSQ-M-Short version was higher than the AUC for the original version, and the difference between the areas was 0.10 (95% CI = 0.02-0.19), which was statistically significant (z = 2.49; P = 0.01). The internal consistency of TSQ-M-Short, as measured by chronbach's α, was 0.34 (95% CI = 0.15-0.48). The construct validity demonstrated a 3-factor structure, which explained 55% of the variance. CONCLUSION: The TSQ-M-Short has an overall diagnostic accuracy which is better than the original TSQ-M. Although the original version includes symptoms for more mental health disorders, providing a wider screen. This short version will prove useful in big-data studies.

A meta-analysis of the diagnostic accuracy of Autism Diagnostic Observation Schedule Module-1 for autism spectrum disorders.

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(M1)) 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(M1) using the original diagnostic algorithm in detecting ASD. Primary results of Sensitivity (Sn), Specificity (Sp) and Diagnostic Odds Ratio (DOR) for ADOS(M1) 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(M1). 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 4057 children. The pooled Sn, Sp, DOR and SROC-AUC for the overall diagnostic accuracy of ADOS (M1) were: 0.91 (95 %CI=0.89 to 0.93), 0.73 (95 % CI=0.69 to 0.76), 44.20 (95 %CI=15.89 to 122.95) and 0.90 respectively [corrected]. Meta-regression analysis showed a non-significant relationship between ADOS(M1) and study quality as well as sample size. There were subgroup differences in the DOR. CONCLUSIONS: It is concluded that ADOS (M1) with the original diagnostic algorithm has the overall diagnostic accuracy and pooled specificity suggesting moderate accuracy. The pooled sensitivity is high to be used as a screening test for Autism Spectrum Disorders. ADOS( M1)with the revised diagnostic algorithm should be used for diagnostic purpose [corrected] ADOS(M1) with the revised diagnostic algorithm should be used instead for the diagnosis of this group of disorders.

CDC Kerala 8: Effectiveness of a clinic based, low intensity, early intervention for children with autism spectrum disorder in India: a naturalistic observational study.

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.

Pre-intervention predictors for acquisition of adaptive behavior among children with intellectual disability.

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.

ADD-H-Comprehensive Teacher's Rating Scale (ACTeRS): a measure for attention deficit hyperactivity disorder among children with intellectual disability in India.

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.

CDC Kerala 9: Effectiveness of low intensity home based early intervention for autism spectrum disorder in India.

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.

ADad 2: the validation of the Screen for Child Anxiety Related Emotional Disorders for Anxiety Disorders among adolescents in a rural community population in India.

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.

ADad 8: School Phobia and Anxiety Disorders among adolescents in a rural community population in India.

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.

ADad 10: the impairment in Anxiety Disorders among adolescents in a rural community population in India.

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.

ADad 4: the symptomatology and clinical presentation of Anxiety Disorders among adolescents in a rural community population in India.

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.

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 Gesell's 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.

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 3: psychotherapy and other non-pharmacological interventions.

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.

Comparison of a self-rated and a clinician-rated measure for identifying depression among adolescents in a primary-care setting.

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.