CAPMH Corner (Updated Dec 2022)

Child and Adolescent Psychiatry and Mental Health (CAPMH)is the official IACAPAP Journal. The "CAPMH Corner" of the December 2022 issue of IACAPAP Bulletin summarizes the following three studies recently published in CAPMH – A national prevalence and profile of single and multiple developmental delays among children aged from 1 year up to 12 years: an Egyptian community‑based study (Metwally et al., 2022), Depression and suicidal behavior among adolescents living with HIV in Botswana: a cross‑sectional study (Olashore et al., 2022) and Cognitive‑behavioral teletherapy for children and adolescents with mental disorders and their families during the COVID‑19 pandemic: a survey on acceptance and satisfaction (Meininger et al., 2022).

Metwally et al., (2022) briefly allude to the adverse consequences of childhood developmental delays (DDs) and build a context to establish the need for estimating their prevalence in the Egyptian context. They conduct a national community-based cross-sectional survey in eight governorates representing all geographic regions of Egypt over a period of 24-months.  

The team recruits parents or caregivers of all children aged 12 months to 12 years by surveying 22,026 houses from 45 blocks (1 or 2 blocks per selected city and 1 or 2 villages per local rural unit). However, they exclude children with known or previously diagnosed developmental disabilities. They carry out face-to-face interviews with caregivers to gather relevant socio-demographic data and the birth history of their children. On the basic premise that adaptive behaviour may constitute the fundamental developmental outcome, they choose the Arabic version of the Vineland Adaptive Behavior Scales, (VABS) [Alotibi, 2004] as a screening measure. They train 64 social workers to use the questionnaire, who pilot it on 80 participants to validate the items of the questionnaire. The team surveys 41,640 children out of whom they refer 3193 children to the health centers of the Ministry of Health and Population (MOHP). On referral, 2778 children (87% of those referred) receive a diagnosis of developmental delay. They use odds ratios (OR), 95% confidence intervals (CI) and logistic regression analysis to analyse their data. 

The authors report an overall prevalence of 6.7% of developmental delays (3.9% of a single DD and 2.8% of multiple DDs) in children. They report the highest prevalence of one delay in children aged 6–12 years and that of two and more delays in children aged 3–6 years. They identify that boys are one and three-quarters more likely than girls to be diagnosed with any developmental delays and that children from urban localities have higher odds of DDs than those from rural areas. They record communication deficit as the most prevalent type (5.3%) of DD, report deficits in daily life skills (self-help and adaptive behaviour) in 2.3% of children, fine motor delay in 1.0% of children, gross motor delay, and socialization deficit in 1.5% of children each. They observe that children living without mothers and/or fathers in homes are associated with increased odds of having DDs by one and a half times (OR = 1.72 and OR = 1.34 respectively). They identify predictors of developmental delays using the multiple logistic regression analysis viz. convulsions after birth (OR = 3.10), low birth weight babies (OR = 1.94), male sex (OR = 1.75), mothers having health problems during pregnancy (OR = 1.70), difficult labour (OR = 1.55), and belonging to middle socioeconomic status (OR = 1.41). While other perinatal factors such as maternal health problems, neonatal cyanosis, and newborn kept in an incubator for more than two days, increase the risk of DDs by almost one and half times, higher paternal and maternal education decreases the odds of having any DDs by 40% (OR = 0.60 and OR = 0.58 respectively). 

The authors highlight that this study is the first to estimate the national prevalence of developmental delays derived from community-based data and that the team has used a reliable and sensitive assessment tool. They also mention that they did not study the environmental and nutritional factors contributing to developmental delays. They recommend developmental screening in all primary care settings as a routine practice to promote early detection and intervention in suspected cases of delayed development. 

Olashore et al., (2022) highlight the disease burden of depression in adolescents and the need to study depression and suicidal behaviour in adolescents living with HIV (ALWHIV) in Botswana which ranks among the top four countries most affected by HIV. They further elaborate that ALWHIV constitute a third of the source of new infections in Botswana and that there was a spike in depression and suicidal behaviour in young people from this region.  

The team recruits a total of 622 adolescents aged 12-19 both English and Setswana-speakers from Botswana Baylor children’s clinical center of excellence (BBCCCE) located in Gaborone (the capital city of Botswana), and the regional HIV care clinics in Mahalapye and Lobatse by convenience sampling in their cross-sectional study. They train five research assistants (psychology graduates) to administer and score the instruments viz. DSM-5 criteria for alcohol use disorder, and the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) modules on depression and suicidal behavior are used. They collect relevant sociodemographic (age, ethnicity, religious participation, parents’ marital status, level of education and occupation) and clinical (viral load, frequency of clinic attendance, and feelings about HIV status) data. They use mean and percentages to present their data and binary logistic regression model to explore the predictors of depression and suicidal behaviour in ALWHIV. The principal investigator, who is a psychiatrist, manages the participants identified as having clinical depression or suicidal ideation and refers those requiring further treatment, especially inpatient care appropriately without breaching confidentiality. 

The team reports the following findings – 54.3% (n=338) males, the mean age (SD) of the participants as 17.7 (1.60) years, 60 (9.7%) have poor clinic attendance, about a quarter (26.1%) of the participants have poor viral suppression, as indicated by a viral load of 400 copies and above, which is the Botswana cut-off, one-third (n = 174, 33.8%) report feeling bad about their HIV status, and 17% report having drinking problems or AUD, 147 (23.6%) meet the criteria for a current depressive episode, prevalence of suicidal behavior (in the past one month) is 117 (18.8%), of which 33 (5.3%) have a severe risk of committing suicide. Female participants are almost two times more likely to be depressed (AOR = 1.96; 95% CI 1.11–3.45) and to have suicidal behavior (AOR = 6.60; 95% CI 3.19–13.7) than their male counterparts. Loss of mother (AOR = 2.87; 95% CI 1.08–7.62) and having a viral load of 400 copies and above (AOR = 5.01; 95% CI 2.86–8.78) are significantly associated with depression. They observe that perceived good support from the healthcare providers, family, relatives, or friends is protective against depression, and frequent or regular participation in religious activities is protective against suicidal behaviour. 

The authors acknowledge the strengths (the first study to establish the prevalence of depression and suicidal behavior using a rigorous diagnostic tool in the ALWHIV in Botswana) and limitations (data collected during the COVID-19 pandemic, which may have affected the clinic attendance). They highlight that although the findings may not be generalizable to rural settings of Botswana, the sample was drawn from the largest center, which serves over 60% of the ALWHIV in the country. They recommend routine psychologic screening (identifying disorders, psychological stressors, and maladaptive coping) as part of the management package for ALWHIV in Botswana and implementation of integrated HIV care programs such as adolescent-friendly services, family and caregiver support services, and psychosocial support platforms. 
 

Meininger et al., (2022) review the benefits and drawbacks of teletherapy for children and adolescents with mental health ailments and set out to evaluate the implementation, acceptance of and satisfaction with teletherapy in a large sample of patients (children and adolescents) of the outpatient unit for cognitive behavioral therapy at the School for Child and Adolescent Cognitive Behavior Therapy (AKiP). 

The team invites therapists and parents of all patients treated (face-to-face or teletherapy) at the outpatient unit of AKiP in the first quarter of 2020 (N = 878) to participate in their survey on the impact of the COVID-19 pandemic on the patient’ wellbeing and treatment. They develop a questionnaire to assess the implementation of and satisfaction with teletherapy for the purpose of this study that contains 15 items in the therapist version (T) and 11 in the parent version (P). They administer the parent version (14 items) and an analogously developed therapist version (six items) of Corona Child Stress Scale (CCSS) (Nikolaidis et a., 2021), besides the questionnaire to assess the implementation of and satisfaction with teletherapy. The team sends out these questionnaires by email to therapists and by email or post to parents. German versions of Child Behavior Checklist (CBCL/6‑18R), Youth Self Report (YSR/11‑18R) [Döpfner et al., 2014], German Symptom Checklist for Screening Behavioral and Emotional Problems (FBB‑SCREEN and SBB‑SCREEN; [Döpfner et al., 2017] are routinely collected at AKiP as part of the standard intake assessment. They descriptively analyze the study questionnaire and use Wilcoxon test, Pearson correlations, Spearman’s rank correlation for additional analysis. 

A total of 643 patients (73%) provide consent and are included in the analyses. Both therapist- and parent- ratings are available for 145 patients. The age range of patients is 3–20 years. They report relatively more male patients (56% males), a clinical diagnosis of an externalizing disorder in approximately 33% and an internalizing disorder in about 40% of the patients. They note that 180 patients (28% of the total sample) did not participate in teletherapy. Therapists cite: (1) the therapy had just started or was paused or terminated (32%), (2) lack of parental or patient consent (29%), (3) technical conditions not met (19%), and (4) teletherapy contraindicated (18%) as the reasons for not switching to teletherapy.  

In most cases, the therapists rate that patients' (72%) and caregivers’ (77%) satisfaction did not change due to the switch to teletherapy. As per parent-ratings, in most cases they did not observe any change in parents’ treatment satisfaction (77%) or child’s satisfaction (65%) following the switch to teletherapy. A third of parents report that they did not intend to use teletherapy in the future. However, parents report a significantly higher intention to use teletherapy in the future than do therapists overall. The authors note that the correlations between treatment satisfaction and child psychopathology are low; therapist satisfaction with teletherapy is higher for patients with higher psychosocial functioning and for those with lower therapist-rated stress due to the COVID-19 pandemic. The number of teletherapy sessions correlates positively with therapist-rated satisfaction and parent-rated treatment satisfaction. They do not observe significant correlations between parent-rated treatment satisfaction and the severity of patients’ symptoms, stress, or psychosocial functioning. 

The authors acknowledge and suggest future studies to address the limitations of their current study, including the lack of assessment of patients’ self-ratings, and the need to explore more factors influencing satisfaction with teletherapy and to consider the time of treatment and assessments prior to switching to teletherapy; the possibility of using qualitative and mixed-methods approaches to study multiple preferences; and to examine the therapeutic relationship in patients who have not previously met their therapists in face-to-face sessions. Overall, they indicate that the challenges of the switch to teletherapy in the context of the pandemic are manageable and that a continuation of psychotherapeutic care is possible in times of crisis for most patients. They see an opportunity to expand this mode of intervention and improve therapeutic care in the long term. 

REFERENCES:  
Alotibi, B. The Vineland Adaptive Behavior Scales – the Saudi version. Arabian J Special Educ. 2004;5:e54. 

Döpfner M, Plück J, Kinnen C. Manual deutsche Schulalter-Formen der Child Behavior Checklist von Thomas M. Achenbach. Göttingen: Hogrefe; 2014. 

Döpfner M, Görtz-Dorten A. DISYPS-III—Diagnostik-System für psychische Störungen nach ICD-10 und DSM-5 für Kinder und Jugendliche—III. Bern: Hogrefe; 2017. 

Meininger, L., Adam, J., von Wirth, E. et al. Cognitive-behavioral teletherapy for children and adolescents with mental disorders and their families during the COVID-19 pandemic: a survey on acceptance and satisfaction. Child Adolesc Psychiatry Ment Health 16, 61 (2022). https://doi.org/10.1186/s13034-022-00494-7 

Metwally, A.M., Abdallah, A.M., Salah El-Din, E.M. et al. A national prevalence and profile of single and multiple developmental delays among children aged from 1 year up to 12 years: an Egyptian community-based study. Child Adolesc Psychiatry Ment Health 16, 63 (2022). https://doi.org/10.1186/s13034-022-00498-3 

Nikolaidis A, Paksarian D, Alexander L, Derosa J, Dunn J, Nielson DM, et al. The Coronavirus Health and Impact Survey (CRISIS) reveals reproducible correlates of pandemic-related mood states across the Atlantic. Sci Rep. 2021;11:8139. 

Olashore, A.A., Paruk, S., Tshume, O. et al. Depression and suicidal behavior among adolescents living with HIV in Botswana: a cross-sectional study. Child Adolesc Psychiatry Ment Health 16, 62 (2022). https://doi.org/10.1186/s13034-022-00492-9 
 

IACAPAP Bulletin, issue 68