Individual and environmental factors in internalizing disorders in children and adolescents.

BACKGROUND: Literature has emphasized the role of biopsychosocial factors in internalizing disorders; however, the role of developmental competencies of a child have not been explored much in this context. The current study aimed to understand the differences in developmental competencies, temperament, parenting practices and psychosocial adversities between children with and without internalizing disorders. METHOD: The sample consisted of 200 children and adolescents aged seven to 18 years, with equal number of those with and without an internalizing disorder; and one of their parents. Psychopathology, temperament, interpersonal competence, emotion regulation, executive function, self-concept, adaptive behaviour, parenting practices, life events, family environment and abnormal psychosocial situations were measured using standardized tools. FINDINGS: Discriminant analysis revealed that temperamental domains of sociability and rhythmicity, developmental competencies of adaptive behaviour and self-concept, parenting practices involving father's involvement and overall positive parenting differentiated the clinical and control groups better. Among psychosocial adversities, family environment domains of cohesion and organization, and subjective stress from life events and abnormal psychosocial situations were the most important discriminators. CONCLUSION: The current study reveals that specific individual factors involving temperament and developmental competencies and environmental factors involving parenting practices and psychosocial adversities are significantly associated with internalizing disorders. This has implications for the mental health care of children and adolescents with internalizing disorders.

Developmental competencies, temperament, parenting practices and psychosocial adversities in children with internalising disorders - A pilot study.

Research on the aetiology of internalising disorders has focussed on biological and environmental factors, however, the role of developmental competencies that a child acquires has not been explored much. The current report aimed to understand the association among the developmental competencies, temperament, parenting practices and psychosocial adversities in internalising disorders. The sample consisted of 30 children and adolescents with internalising disorders belonging to the age group of six to 18, and one of their parents. All the participants were assessed for functional impairment, temperament, interpersonal competence, emotion regulation, executive function, self-concept, adaptive behaviour, parenting practices, life events and family environment using standardised tools. The findings revealed that positive parenting shares a negative relationship with functional impairment(ρ=-0.62; p <.001). On comparison with non-clinical samples in previous studies, interpersonal competence and self-concept were found to be at lower levels in the current sample. In conclusion, the current study indicates that children with internalising disorders differ from control groups in specific developmental competences. These findings have specific implications for intervention and research in the area of internalising disorders in children and adolescents.

Hydrothermal and thermal-alkali pretreatments of wheat straw: Co-digestion, substrate solubilization, biogas yield and kinetic study.

Agro-waste having lignocellulosic biomass is considered most effective (heating value 16 MJ/kg) for energy production through anaerobic digestion (AD). However, recalcitrant lignocellulosic fraction in agro-waste obstructs its biotransformation and is a rate-limiting step of the process. This study investigated the effects of hydrothermal and thermal-alkaline pretreatment on anaerobic co-digestion of wheat straw (WS). The hydrothermal pretreatment of WS revealed that 60 min was the best pretreatment time to achieve the highest substrate solubilization. It was employed for thermal-alkali pretreatment at variable temperatures and NaOH doses. Thermal-alkali pretreatment at 125°C-7% NaOH shows the highest (34%) biogas yield of 662 mL/gVS, followed by 646 mL/gVS biogas yield at 150°C-1% NaOH assay (31% higher) over control. Although the 125°C-7% NaOH assay achieved the highest biogas yield, the 150°C-1% NaOH assay was found more feasible considering the cost of a 6% higher chemical used in the earlier assay. The thermal-alkali pretreatment was observed to reduce the formation of recalcitrant compounds (HMF, Furfural) and increase the buffering capacity of the slurry over hydrothermal pretreatment. Principal component analysis (PCA) of the various pretreatment and AD operational parameters was carried out to study their in-depth correlation. Moreover, a kinetic study of the experimental data was performed to observe the biodegradation trend and compare it with the Modified Gompertz (MG) and First Order (FO) models.

Critical insights into anaerobic co-digestion of wheat straw with food waste and cattle manure: Synergistic effects on biogas yield and kinetic modeling.

In this study, four batch assays were performed to ensure the synergic effects of co-digestion and find out the best inoculums to substrate ratio (ISR), carbon to nitrogen ratio (C:N), and total solid (TS) percentage in sequence. The co-digestion of three feedstocks had a 20% higher biogas yield (416 mL/gVS added) than mono-digestion with 21% volatile solids (VS) degradation. The ISR of 2 leads to the highest biogas yield (431 mL/gVS added) and VS removal (30.3%) over other ISRs (0.5, 1.0, 2.5) studied. The lower ISR (<2) tended to have lower pH due to insufficient anaerobes inside the digester. The C:N 35 (with ISR 2) yielded 17.4% higher biogas (443.5 mL/gVS added) than mono-digestion and was the highest among the C:N ratios studied with 36.6% VS removal. The VFA, alkalinity, and pH in C:N 35 assay were more stable than in other C:N assays. In the fourth batch assay, varying TS% (5, 7.5, 10, 12.5) were used with optimized ISR (2) and C:N (35). Higher TS% (10 and 12.5) had some lag phase but later achieved higher biogas production. The 12.5% TS assay achieved 80% higher biogas yield (679 mL/gVS added) over mono-digestion, i.e., highest among the TS% studied, with 48% VS removal. In conclusion, co-digestion of mixed feedstocks with ISR 2, C:N 35, and TS 12.5% could degrade almost half of the substrate available for biodegradation. Further biodegradation may require pretreatment of the recalcitrant WS. Modified Gompertz, first-order, transference, and logistic models were used for kinetic study and curve fitting of experimental data. For the optimized batch assays, the estimated specific rate constants were 0.08, 0.12, 0.083, and 0.084. The data fits well in all the models, with the coefficient of discrimination (R2) ranging from 0.882 to 0.999.

Lived Experiences of Siblings of Individuals with Autism Spectrum Disorder in India: An Interpretative Phenomenological Analysis.

Background: Autism spectrum disorder (ASD) can impact the individual and their families. The impact on siblings is unique because they evolve from being another child in the family to a future adult who can be a potential resource to the family in supporting a member with ASD. Since the quality of care and support can be affected by the lived experiences of the carer and there are not many studies on siblings, this study examined the lived experiences of siblings of individuals with ASD. Methods: Fourteen siblings of individuals with ASD, aged 15-36 years, were recruited from a tertiary hospital, schools, and private institutes. A semistructured interview schedule was used to explore the lived experiences. Interpretative phenomenological analysis (IPA) was used to identify the themes. Results: The themes based on IPA indicated that the siblings have very basic concerns like understanding the condition and complex issues such as coping, preparing for current and future roles, personal needs and expectations, need for a support system, and positive aspects of the sibling relationship. Nonetheless, the siblings minimized reporting their difficulties and focused more on the needs of the sibling with ASD. Conclusion: Siblings have diverse lived experiences, with a small element of positive experiences. Appropriate supports are needed to address the complexities of the lived experiences.

Predictors of behavioral and emotional issues in children involved in custody disputes: A cross sectional study in urban Bengaluru.

BACKGROUND: The increasing rates of divorce in urban India has led to the subsequent parental battle for the child's custody. This paper discusses the behavioral and emotional issues of these children in relation to their psychosocial environmental factors and other relevant socio-demographic variables. METHODS: We used samples from parent interviews concerning 52 children aged 7-17-years-old, involved in child custody cases in the Family court of urban Bengaluru. The Strengths and Difficulties Questionnaire was used to measure response variables of behavioral and emotional issues in these children. Predictor models of quantile and multiple linear regression were used to assess the influence of psychosocial environmental factors and socio-demographic variables on the response variables. RESULTS: The predictor models revealed that risk of child suffering emotional and behavioral issues increased with factors such as excessive parental control, change of academic environment, general unrest at school, frequency of child's court visit, child's visitation of non-custodian parent on occasions and vacations, and negatively altered family relationship. The model however intriguingly showed that residing in nuclear household rather than with their grandparents in a non-nuclear household, decreased the risk of mental health issues in these children. CONCLUSIONS: This study is a novel attempt to understand the influence of the psychosocial issues on the child's mental health in the context of custody cases in India. Despite the minimum sample size, the findings imply that family-based intervention is the need of the hour in these cases. The implications for clinical practice and research are discussed.

Does Preoperative Function Affect the Outcome Following Pyeloplasty in Poorly Functioning Kidneys among Pediatric Population?

AIM: To determine the efficacy and outcome of pyeloplasty in poorly functioning kidneys in the pediatric population and whether pyeloplasty could be offered as an upfront procedure in such patient population, instead of nephrectomy. MATERIALS AND METHODS: A retrospective data analysis of 83 patients who underwent pyeloplasty in poorly functioning kidneys from 2010 to 2015 was performed. Success was defined based on improvement in symptoms, stable or improved function, and better drainage on post-operative Tc-99m Diethylene Triamine Pentaacetic acid scan instead of DTPA scan renography done after 3 months and yearly thereafter. RESULTS: Eighty-three patients with a mean age of 6.8 ± 2.88 years with poor function on isotope renogram (<30%) were included in the study. Three patients were excluded in view of postoperative outflow obstruction. Out of the remaining 80 patients, 56 were male and 24 were female. They were divided into two groups based on preoperative differential renal function (DRF), Group I (n = 26) having preoperative DRF of <10% and Group II (n = 54) having preoperative DRF of 10%-30%. All patients underwent laparoscopic dismembered pyeloplasty with ureteral stenting. The mean DRF improved from 7.58 ± 2.39 to 29.71 ± 5.16 postoperatively in Group I. However, in Group II, DRF improved from 20.81 ± 5.68 to 37.25 ± 7.11 postoperatively. At a follow-up of 24 months, the overall success rate was 98%. CONCLUSION: Pyeloplasty gives good intermediate-term results even in extremely poorly functioning kidneys and an upfront pyeloplasty instead of nephrectomy should be offered to all pediatric patients irrespective of preoperative function.

Swatantra Clinic: A descriptive study on the specialized child mental health service for children in difficult circumstances at a tertiary care center in India.

In India, children in difficult circumstances, like institutionalized children have higher mental health morbidity and complex psychosocial concerns than the non-institutionalized children. To cater to the complex needs of these children referred by the Juvenile Justice System, a specialized service called 'Swatantra Clinic' was initiated by the Department of Child and Adolescent Psychiatry at the National Institute of Mental Health and Neurosciences, India. This article thereby aims to describe the psychosocial characteristics of these children, along with the array of specialized interventions provided during the first year of its inception in June 2018. It was found that majority of these children were girls and were from lower socio-economic, urban background, primarily referred for externalizing or internalizing concerns. The majority of them reported experiences of physical and verbal abuse along with family stressors and almost half of them had a diagnosable psychiatric condition. The nature of the psychosocial services rendered at the clinic mostly comprised of brief, individual and family counseling along with liaison work with various governmental agencies for rehabilitation services. These form the key components of a comprehensive, collaborative, time-bound and holistic care model to cater to the distinct psychosocial issues of this vulnerable population of children in low - middle resource settings. Policy implications are discussed.

Addressing Emotional Issues in an Adolescent with Vitiligo and Early Child Sexual Abuse-Therapeutic Challenges.

Chronic medical conditions in children and adolescents have a significant impact on development and quality of life. Children with vitiligo experience depression, anxiety and guilt, body image concerns, and conflicts of acceptance-rejection among peers. Understanding issues of relevance through a developmental perspective is pivotal. Here, we report the experiences of working with an adolescent who presented with depressive symptoms, mood dysregulation, and self-harm, in the background of vitiligo and child sexual abuse. We describe the unique therapeutic challenges, focusing on the interplay between depressive psychopathology, childhood trauma, and normative adolescent development. Therapeutic strategies for patient-centered psychological interventions are discussed. The therapy processes focused on a narrative approach, with the active involvement of the family.

Preschool-onset OCD: A review of literature and clinical experience.

Obsessive-compulsive disorder (OCD) has been described in preschool children as young as 2-3 years old. A preschool age onset of OCD has unique diagnostic and therapeutic challenges. In this article, the authors review published literature on preschool onset OCD and present data on preschool-onset OCD (age of onset ≤ 5 years) from clinical records at a tertiary care child and adolescent psychiatry center in India. Literature suggests that OCD that starts this early is phenomenologically similar to OCD in older individuals; however, it has very high rates of comorbidity and a family history of OCD. There is a paucity of data on course, treatment, and long-term outcome in this group. At their center, the authors found a 3% prevalence of preschool-onset OCD, with a male predominance (69%) and fairly high comorbidity rates (62%). Qualitative review highlighted delay in treatment seeking, poor follow-up rates, frequent use of pharmacological treatment, and a high remission rate in those treated adequately.

Emerging behavioral and neuroimaging biomarkers for early and accurate characterization of autism spectrum disorders: a systematic review.

The possibility of early treatment and a better outcome is the direct product of early identification and characterization of any pathological condition. Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairment in social communication, restricted, and repetitive patterns of behavior. In recent times, various tools and methods have been developed for the early identification and characterization of ASD features as early as 6 months of age. Thorough and exhaustive research has been done to identify biomarkers in ASD using noninvasive neuroimaging and various molecular methods. By employing advanced assessment tools such as MRI and behavioral assessment methods for accurate characterization of the ASD features and may facilitate pre-emptive interventional and targeted therapy programs. However, the application of advanced quantitative MRI methods is still confined to investigational/laboratory settings, and the clinical implication of these imaging methods in personalized medicine is still in infancy. Longitudinal research studies in neurodevelopmental disorders are the need of the hour for accurate characterization of brain-behavioral changes that could be monitored over a period of time. These findings would be more reliable and consistent with translating into the clinics. This review article aims to focus on the recent advancement of early biomarkers for the characterization of ASD features at a younger age using behavioral and quantitative MRI methods.

Specific learning disability in the context of current diagnostic systems and policies in India: Implications for assessment and certification.

Specific Learning Disability (SLD) is a neurodevelopmental disorder with significant problems in language processing, which are evident through difficulties in reading, writing, spelling, and mathematics. SLD was notified as a disability by the Government of India in 2016. Until then, it was primarily left to the discretion of the individual education boards to decide the assessment procedures and support measures for a child suspected to have SLD. However, with the enforcement of the Rights of Persons with Disabilities Act 2016 (RPWD Act), there is a legal binding to follow specific guidelines for assessment and certification mentioned in the RPWD Act. Nonetheless, there are issues inherent to the construct of SLD described in the diagnostic manuals and the current certification processes under the RPWD Act. In this context, this paper highlights the discrepancies in the requirements of the RPWD Act and the diagnostic criteria of the International Classification of Diseases -10 (ICD-10) and the Diagnostic and Statistical Manual- 5 (DSM-5) and draws implications for assessment and certification procedures which will affect the lives of millions of children in the Indian context. It also presents potential solutions and possible future directions related to the assessment of the SLD.

Crossing barriers: Role of a tele-outreach program addressing psychosocial needs in the midst of COVID-19 pandemic.

Novel Coronavirus disease 19 (COVID 19) pandemic has affected more than 2 million individuals and causing over 0.1 million deaths worldwide. In India, the pandemic has gained momentum in the last few weeks with over 10,000 cases and 400 deaths. In the absence of any pharmacological cure on the horizon, countries have resorted to the use of strict public health measures to curtail spread of further infection to fight the coronavirus. The pandemic and its social implications have triggered mental health concerns among the masses. Providing psychological first aid and psychosocial support is vital in mitigating the distress and enhance the coping strategies of people to deal with this biological disaster. Tele-mental health services play an important role in this regard. In this article we describe our preliminary experience in understanding the psychological concerns of general public and addressing them by providing psychological support through a national telephonic helpline.

Clinical Profile of Tic Disorders in Children and Adolescents from a Tertiary Care Center in India.

BACKGROUND: Tic disorders (TDs) are common neurodevelopmental disorders in children and adolescents. To date, there is very scant literature on TDs in children and adolescents in the Indian setting. AIM: The objectives of this study were to characterize the clinical profile, including comorbidities and pattern of medication use in the treatment of TDs, in children and adolescents. MATERIALS AND METHODS: The present study is a retrospective chart review of children and adolescents up to age 18 years diagnosed with TD in a tertiary care center in India. Data were derived from case records of patients with a diagnosis of TD, coded as F 95 according to ICD 10, from 1st January 2014 to 31st December 2017. RESULTS: We recruited 85 subjects. The majority (95.29%, n = 81) of them were male, and the mean age of onset was 8.4 years. Chronic tic disorder was the most common subtype, followed by Tourette syndrome and provisional or transient tic disorder. Eighty patients (94%) had a comorbid disorder, with attention deficit hyperactivity disorder being the most common, followed by obsessive compulsive disorder. Eighty-two percent of patients received pharmacotherapy. Risperidone was the most frequently used medication, followed by clonidine, haloperidol, and aripiprazole. Moderate to significant improvement with medications was seen in 88% of the patients. CONCLUSION: The present study of children and adolescents with TDs highlights very high rate of comorbidity and a favorable short-term course with medication use.

Child and adolescent psychiatry training in Nepal: early career psychiatrists' perspective.

BACKGROUND: Nepal is a developing low-income country in Southeast Asia. There is a huge burden of child and adolescent mental health (CAMH) in Nepal which has a population of around 29 million and 40-50% of the population comprises of children and adolescents. Child and Adolescent Psychiatry (CAP) has not been formally recognized as a subspecialty in Nepal and there is no standardized curriculum for CAP training. The objectives of the survey were to identify the current status of training, shortfalls and to explore the training experiences of early career psychiatrists (ECPs) in Nepal. METHODS: The participants were ECPs in Nepal. An online questionnaire was created consisting of 20 questions including 3 questions requiring an answer indicating a level of agreement scored on a ten-point scale. Questionnaire using google form was e-mailed with the uniform resource locator (URL). Respondents anonymously answered the questions. The survey was open from 01/01/2019 to 01/04/2019. RESULTS: Response rate was 83.69%. Around 42% (n = 32) were trainees in Doctor of Medicine (MD) Psychiatry and 58% (n = 45) of respondents had completed their MD Psychiatry. More than half of the ECPs had not received formal training specific to CAP. Seventy percent (n = 54) ECPs reported that their current workplace did not have a specific unit to address psychological problems in children and adolescents. However, 62% (n = 48) of ECPs came across 10 CAP cases per week. On a ten-point scale, mean score of ECPs confidence in diagnosing, management and overall confidence in CAP cases were 5.18 ± 1.56, 4.58 ± 1.59 and 4.67 ± 1.62 respectively. Fifty-four percent (n = 42) of respondents rated their training as limited and 74% (n = 57) of them wanted additional training in CAP. Psychological intervention, psychotherapy and a fellowship course were the additional training most of the ECPs wanted to receive. CONCLUSION: Despite significant exposure to CAP patients in daily practice, ECPs self-evaluated their training as inadequate and there is no standardized CAP training program in Nepal for ECPs. The desire of ECPs to receive additional training in CAP is highly encouraging and positive. We advocate for the development and incorporation of CAP training in current psychiatry training to fulfill these unmet training needs in Nepal.

Adolescence: Contemporary issues in the clinic and beyond.

This article reports on a Continuing Medical Education Programme (CME), organized by the Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, in March 2019. The theme, Adolescence: contemporary issues in the clinic and beyond, aimed to cover 'lesser understood and challenging' areas in adolescent mental health. The CME was attended by over 200 professionals from various fields - clinicians, post-graduate students in psychiatry, psychology and psychiatric social work, school counsellors, and members of non-governmental organisations working in the areas of childcare and law. The article covers key messages from the 8 sessions in this CME.

Eye movement tracking in pediatric obsessive compulsive disorder.

Till date researchers have elucidated the neurobiological substrates in OCD using methods like neuroimaging. However, a potential biomarker is still elusive. The present study is an attempt to identify a potential biomarker in pediatric OCD using eye tracking. The present study measured pro-saccade and anti-saccade parameters in 36 cases of pediatric OCD and 31 healthy controls. There was no significant difference between cases and controls in the error rate, peak velocity, position gain and latency measures in both pro-saccade and anti-saccade eye tracking tasks. With age, anti-saccades become slower in velocity, faster in response and more accurate irrespective of disorder status of the child. Pro-saccades also show a similar effect that is less prominent than anti-saccades. Gain measures more significantly vary with age in children with OCD than the controls, whereas latency measures positively correlated with age in children with OCD as opposed to being negatively correlated in the controls. Findings of this study do not support any of the eye tracking measures as putative diagnostic bio-markers in OCD. However, latency and gain parameters across different age groups in anti-saccade tasks need to be explored in future studies.

Interventions for Childhood Anxiety Disorders - What Works Best from a Child's Perspective: A Qualitative Study.

BACKGROUND: Anxiety spectrum disorders are the most prevalent psychopathology among children and adolescents. Qualitative research in childhood anxiety disorders can provide valuable insights regarding interventions. The objectives of this study were to examine the child's perspectives on the subjective experience of concerns, the impact of the symptoms on socioacademic functioning, and the process of recovery with interventions. METHODS: Children and adolescents aged 6-16 years, presenting with any subtype of anxiety spectrum disorder as per International Classification of Diseases and Related Health problems, 10th Revision (ICD-10) Diagnostic Criteria for Research, were included. Convenience sampling was used, and 30 children fulfilling inclusion and exclusion criteria were selected. An interview guide with simple questions to facilitate response was used, at the baseline and 12th week of follow-up, to generate a written narrative account of the experience of concerns, the impact of symptoms, and the treatment process. Children received treatment as usual, which included a workbook-based cognitive behavioral intervention. RESULTS: Content analysis was done using 30 baseline and 20 follow-up narratives. Clustering of themes were done. Themes related to the recovery process reflected perceived improvement in academic performance and competence, apart from the improvement in symptoms. There were more themes in favor of cognitive interventions. CONCLUSION: Children's narratives highlight the importance of cognitive interventions for anxiety disorders.

Favourable short-term course and outcome of pediatric anxiety spectrum disorders: a prospective study from India.

BACKGROUND: Although anxiety disorders are the most prevalent psychiatric disorders among children and adolescents, there is a paucity of research on the course and outcome of anxiety spectrum disorders in low and middle-income countries. METHODS: 60 children and adolescents aged 6-16 years with anxiety spectrum disorders attending the child and adolescent psychiatry department in a tertiary care center from India were included after taking written informed consent and assent in this prospective study conducted between April 2012 to May 2014. Assessments were done at baseline, 12 weeks and 24 weeks using pediatric anxiety rating scale, clinical global impression-severity, clinical global assessment scale and pediatric quality of life scale; MINI-KID (version 6.0) was used to examine remission status. RESULTS: Mean age of children was 12.68 years and mean duration of illness was 34.52 months. Follow-up rate at 24 weeks was 80% with a remission rate of 64.6%. Socio-demographic factors did not affect the baseline severity or course and outcome measures. Children with greater baseline severity and social phobia had a less favorable outcome at 24 weeks. Improvements made in the initial 12 weeks were maintained at 24 weeks follow up. These findings are in line with earlier studies from high-income countries. LIMITATIONS: Small sample size, attrition, rater bias. CONCLUSION: The study has shown a favorable outcome in children and adolescents with anxiety spectrum disorders receiving treatment-as-usual in a tertiary care setting. Adolescents who present with greater severity, comorbid with other anxiety disorders and depression at baseline require intensive intervention, and long-term follow up. There is a need for interventional research with specific focus on universal preventive programs for anxiety spectrum disorders that are feasible for delivery in low and middle-income countries.