Access to early diagnosis for attention-deficit/hyperactivity disorder among children and adolescents in Mexico City at specialized mental health services.

BACKGROUND: In Mexico, this pioneering research was undertaken to assess the accessibility of timely diagnosis of Dyads [Children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD) and their primary caregivers] at specialized mental health services. The study was conducted in two phases. The first phase involved designing an "Access Pathway" aimed to identify barriers and facilitators for ADHD diagnosis; several barriers, with only the teacher being identified as a facilitator. In the second phase, the study aimed to determine the time taken for dyads, to obtain a timely diagnosis at each stage of the Access Pathway. As well as identify any disparities based on gender and socioeconomic factors that might affect the age at which children can access a timely diagnosis. METHOD: In a retrospective cohort study, 177 dyads participated. To collect data, the Acceda Survey was used, based on the robust Conceptual Model Levesque, 2013. The survey consisted of 48 questions that were both dichotomous and polytomous allowing the creation of an Access Pathway that included five stages: the age of perception, the age of search, the age of first contact with a mental health professional, the age of arrival at the host hospital, and the age of diagnosis. The data was meticulously analyzed using a comprehensive descriptive approach and a nonparametric multivariate approach by sex, followed by post-hoc Mann-Whitney's U tests. Demographic factors were evaluated using univariable and multivariable Cox regression analyses. RESULTS: 71% of dyads experienced a late, significantly late, or highly late diagnosis of ADHD. Girls were detected one year later than boys. Both boys and girls took a year to seek specialized mental health care and an additional year to receive a formal specialized diagnosis. Children with more siblings had longer delays in diagnosis, while caregivers with formal employment were found to help obtain timely diagnoses. CONCLUSIONS: Our findings suggest starting the Access Pathway where signs and symptoms of ADHD are detected, particularly at school, to prevent children from suffering consequences. Mental health school-based service models have been successfully tested in other latitudes, making them a viable option to shorten the time to obtain a timely diagnosis.

La integridad mental del personal clínico de un hospital psiquiátrico, asociada a una alta exigencia emocional y a la organización nociva del trabajo / Mental health integrity of clinical staff at a psychiatric hospital, associated to burn-out toxic management

The Joint Committee on Health at Work make up by: ILO/WHO (International Labour Organization and the World Health Organization) in 1992, recognized that inappropriate management, affects people's health through physiological and psychological mechanisms known as stress. The aim of this study was to evaluate the risks associated to toxic management, and to certain psychological demands; as contributors to mental distress, lack of stress and job dissatisfaction of psychiatrists, vitality psychologists and medical residents of a Child Psychiatric Hospital (CHPH). Material and methods The study design was a cross-sectional survey, descriptive and observational. Instrument: The Copenhagen Psychosocial Questionnaire (The Copenhagen Psychosocial Questionnaire COPSOQ). Originally developed in Denmark, was adapted and validated in Spain. The internal consistency of the scales was Cronbach's a (0.66 to 0.92) and Kappa indices (0.69 to 0.77). Statistical analysis. Descriptive analysis was expressed by means, percentages and standard deviations. Bivariate analysis was calculated between psychosocial factors and dimensions of health. The comparisons between categorical variables were analized through chi square tests, and Fisher's exact test was used when the number of observations in the cells of the contingency table was less than 5. The results were expressed by prevalence ratios and their respective confidence intervals were calculated. Statistical analysis was performed using JMP statistical package version 7 and SPSS version 17. Results A total of 111 clinicians were surveyed: 30 psychiatrists, 46 psychologists and 35 medical residents. The response rate was 97%. The age range of the clinical staff was, from 26 to 65 years, with M=40, SD=6.5 years. Association between psychosocial demands and dimensions of health. Major problems presented by clinical staff, were explained from 3 axes. First axis, about psychological demands. We evaluated five types of psychological demands, but those that emerged as predictors of mental distress, loss of energy and cognitive behavioral stress symptoms, were the emotional demands. Emotional demands had statistically significant associations with mental distress (OR 3.67, 95% CI 1.28-10.01), behavioral symptoms (OR 3.59, 95% CI 1.28-10.06) and cognitive stress (RP 2.15, 95% CI 1.00-5.12) as well as lack of vitality (OR 1.78, 95% CI 1.01-3.13) (table4). Second axis: about quality of leadership, this concept showed statistically significant association with: mental distress (OR 2.83, 95% CI 1.19-6.76), with cognitive symptoms (OR 2.33, 95% CI 1.00-5.60) and behavioral stress (RP 2.24, 95% CI 1.06-4.75) and lack of vitality (OR 1.65, 95% CI 1.06-4.75). Other high-risk concept was: Managers' low social support, that showed statistically significant association with job dissatisfaction (OR 3.08, 95% CI 1.41-6.73), lack of vitality (OR 1.41, 95% CI 1.12-1.78) and mental distress (OR 1.39, 95% CI 1.07-1.81). Within the same second axis of analysis, lack of predictability was significantly associated with: mental distress (OR 2.33, 95% CI 1.40-3.88), behavioral symptoms (OR 2.11, 95% CI 1.31-3.41) cognitive stress symptoms (OR 2.07, 95% CI 1.19-3.61), and lack of vitality (OR 1.63, 95% CI 1.17-2.29). Third axis: the effort-reward imbalance; had a statistically significant association between job insecurity and all dimensions of health such as behavioral symptoms of stress (RP 1.97, 95% CI 1.14-3.41), lack of vitality (RP 1.94, 95% CI 1.23 -3.07), mental distress (RP 1.73, 95% CI 1.04-2.88), and cognitive symptoms of stress (RP 1.39, 95% CI 1.12-1.72). But stronger association was found between insecurity and job dissatisfaction (OR 7.65, 95% CI 1.09-53.75). Hence, the lack of esteem was significantly related to mental distress (OR 2.11, 95% CI 1.12-3.95), with behavioral symptoms of stress (OR 1.82, 95% CI 1.03-3.23), and lack of vitality (OR 1.42, 95% CI 1.00-2.11). Discussion According to Karasek-Theorell's theoretical model, high demands, low control and low social support (the combination of these factors brought together the work of psychiatrists, psychologists and residents) this condition represents the greatest risk to health. Clinical professionals are treated disrespectfully, have no appreciation; causing an effort/reward imbalance in their work. Our results are consistent with research conducted with the same instrument in Sweden, Denmark, Serbia, Germany and Spain. These articles found that psychiatrists and psychologists are exposed to high emotional demands. In contrast a high quality management shows clear relationship to mental well-being, with high vitality and acceptable levels of stress. Our findings show that low social support from managers, increase psychosocial risks and stress findings which are consistent with a Chilean study. Although most participants (except residents) have an acceptable job safety almost eight of every ten respondents claimed to be quite concerned about possible changes or delays in salary, or requiring a second job. Security at work is a fundamental aspect of the model of effort-reward-balance. Lack of this characteristic has a negative impact on human health. The human rights organization in Latin America (HR), found that 33% of latino workers expressed "anxiety" because of job insecurity, furthermore recognized the relationship between job insecurity and an increase in cancer and depression. Latino workers seem to be the most affected by new global order, where employment is based on the informal economy. A poll by the Washington Post, Kaiser Family Foundation and Harvard University affirmed that 33% of latinos expressed "anxiety" by job insecurity, compared with 22% of Afro-American and 20% of white people. Complications in health and life prognosis for these workers and their productivity, affects directly the quality care of the patients, beyond production costs. The Chilean analysis concluded that is necessary to give special attention to health sector working population due to the importance of their work. In conclusion, our results suggest that high emotional demands coupled with a poor quality of leadership, characterized by a highly hierarchical power structure, with low esteem, lack of support and unfair treatment was associated with mental distress, and behavioral symptoms of stress and lack of vitality. The total of these deficiencies and their interaction could potentially cause an effort / reward imbalance in clinician work. From the standpoint of prevention, it is about working there; where the exposures have been identified. The risk factors such as stress need to be controlled from its source: toxic management. It seems relevant to include our proposals, in order to improve organization culture and create healthier environments for the staff, so we recommend: 1) A strategic program to protect health of the hospital staff. 2) To assess and reward the efforts, accomplishments, contributions, results and not permanence. 3) Assign a fair wage according to their preparation and the functions performed. 4) It is necessary that managers and middle managers solve conflict well, plan their job correctly and be able to establish proper communication channels with their subordinates. 5) Promote labor stability. 6) Flexible hours, according to the needs of people and not just production. 7) Working conditions should provide development opportunities and the tasks must be varied and meaningful. 8) Promote teamwork, encourage social support and avoid competition. 9) Strengthen the esteem and recognition, including a promotion plan in terms of expectations of each employee. 10) Eliminate highly hierarchical power structures.

El objetivo de esta investigación fue evaluar los riesgos asociados a las formas nocivas de la organización del trabajo, que unidas a ciertas exigencias psicosociales coadyuvan en la génesis del malestar mental, la falta de vitalidad, el estrés y la insatisfacción laboral de los psiquiatras, psicólogos y residentes del Hospital Psiquiátrico Infantil (HPI). Material y métodos El diseño del estudio fue observacional, transversal y descriptivo. Instrumento. El Cuestionario Psicosocial de Copenhague (The Copenhagen Psychosocial Questionnaire CoPsoQ). El instrumento original de origen danés fue adaptado y validado en España, mostrando tener validez y fiabilidad contrastada, con a de Cronbach (0.66 a 0.92) e índices de Kappa (0.69 a 0.77). Resultados Participaron 111 profesionistas, de los cuales 30 son psiquiatras, 46 psicólogos y 35 médicos residentes. Se obtuvo una respuesta del 97%. La edad mínima del personal clínico se ubicó entre 26 a 35 y la máxima de 56 a 65 años, con una M= 40, DE=6.5 años. Asociación entre las exigencias psicosociales y las dimensiones de salud. Los problemas más apremiantes que presentó el personal clínico se explican a partir de tres ejes. Primer eje, de las exigencias psicológicas: las de tipo emocional tuvieron asociaciones estadísticamente significativas con el malestar mental (RP 3.67, IC95% 1.2810.01), con los síntomas conductuales (RP 3.59, IC95% 1.28-10.06) y cognitivos del estrés (RP 2.15, IC95% 1.00-5.12) así como con la falta de vitalidad (RP 1.78, IC95% 1.01-3.13). El segundo eje, de la calidad de liderazgo: mostró asociación estadísticamente significativa con: el malestar mental (RP 2.83, IC95% 1.19-6.76), con los síntomas cognitivos (RP 2.33, IC95% 1.00-5.60) y los conductuales del estrés (RP 2.24, IC95% 1.06-4.75) y con la falta de vitalidad (RP 1.65, IC95% 1.06-4.75). El escaso apoyo social por parte de los jefes, mostró asociación estadísticamente significativa con la insatisfacción laboral (RP 3.08, IC95% 1.41-6.73), la falta de vitalidad (RP 1.41, IC95% 1.12-1.78) y el malestar mental (RP 1.39, IC95% 1.071.81). Dentro del segundo eje de análisis, la falta de previsibilidad mostró asociación estadísticamente significativa con: el malestar mental (RP 2.33, IC95% 1.40-3.88), con los síntomas conductuales (RP 2.11, IC95% 1.31-3.41) y con los síntomas cognitivos del estrés (RP 2.07, IC95% 1.19-3.61), así como con la falta de vitalidad (RP 1.63, IC95% 1.17-2.29). Tercer eje, del equilibrio esfuerzo-recompensa: se observó asociación estadísticamente significativa entre la inseguridad laboral y todas las dimensiones de salud (síntomas conductuales del estrés (RP 1.97, IC95% 1.14-3.41); falta de vitalidad (RP 1.94, IC95% 1.23-3.07); malestar mental (RP 1.73, IC95% 1.04-2.88) y síntomas cognitivos del estrés (RP 1.39, IC 95% 1.12-1.72). Sin embargo, la asociación de mayor fuerza se observó entre la inseguridad y la insatisfacción laboral (RP 7.65, IC95% 1.09-53.75). Por lo que se refiere a la falta de estima, ésta se asoció en forma significativa con el malestar mental (RP 2.11, IC 95% 1.12-3.95), con los síntomas conductuales del estrés (RP 1.82, IC95% 1.03-3.23) y con la falta de vitalidad (RP 1.42, IC95% 1.00-2.11). Discusión La existencia de la organización nociva en el hospital se explica por medio del modelo demanda-control-apoyo social, en donde los clínicos se exponen a una alta demanda emocional, falta de control y autonomía en el trabajo, aunado a un bajo apoyo social. Esta condición representa la situación de mayor riesgo para su salud. La carencia de respeto, la falta de reconocimiento y el trato injusto podrían ser el origen de un desequilibrio en el esfuerzo-recompensa del trabajo clínico. La pobre calidad de liderazgo, caracterizada por una estructura organizacional y de poder altamente jerarquizada, sumada a la falta de apoyo social, a la inseguridad laboral y a la falta de previsibilidad están afectando de forma muy importante la salud mental de los clínicos del HPI al crear un clima organizacional negativo que contribuye al ausentismo, a la baja productividad y muy probablemente perturba la calidad de la atención a los pacientes. Es necesario, por esto, proteger la integridad mental del personal del hospital.

M-CHAT Mexican Version Validity and Reliability and Some Cultural Considerations.

The Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire is a brief measure available in Spanish which needs to be validated for the Mexican population. Parents of children from (1) community with typical development (TD) and (2) psychiatric outpatient unit completed the CBCL/1.5-5 and the Mexican/MM-CHAT-version. The study sample consisted of 456 children (age M = 4.46, SD = 1.12), 74.34% TD children and 26.65% with Autism Spectrum Disorders (ASD). The MM-CHAT mean score for failed key items was higher for the ASD group compared with the TD group. Internal consistency for the Mexican/M-CHAT version was .76 for total score and .70 for the 6 critical items. Correlations between the MM-CHAT and the CBCL/1.5: PDD and Withdrawn subscales and with ADI-R dimensions: B non verbal) and A were high, and were moderate with ADI-R dimensions B1 (verbal) and C The failure rate of the MM-CHAT between the groups did not reproduce all the critical items found in other studies. Although the instrument has good psychometric properties and can be used for screening purposes in primary settings or busy specialized psychiatric clinics, these results support evidence for cultural differences in item responses, making it difficult to compare M-CHAT results internationally.