childhood developmental and psychological disorders trends in presentation...

Tata Institute of

Social Sciences

THE INDIAN JOURNAL OF

SOCIAL WORK

Volume 75, Issue 4 October, 2014

IJSW, 75 (4), 495–522, October, 2014

articles

Childhood Developmental and Psychological DisordersTrends in Presentation and Interventions in a Multidisciplinary Child Development Centre

CHETNA DUGGAL, SAMIR DALWAI, KRUTIKA BOPANNA, VRINDA DATTA, SOHINI CHATTERJEE AND NITA MEHTA

The prevalence of childhood psychological and developmental disorders is steadily in-creasing. Early identification and a specialised intervention for the same is critical. The present study aimed to highlight the trends in diagnosis and effective interventions for childhood problems in a specialised child development centre. Case reports of 1,301 children visiting the centre were analysed and followed-up with in-depth interviews of 18 stakeholders. The trends and presentations of disorders are explained through syn-dromal, sub-syndromal and co-morbid classifications. Effectiveness of a multidiscipli-nary intervention with a diagnosed disorder is explored. Implications for practice, train-ing, research and policy change are discussed.

Chetna Duggal is an Assistant Professor; Krutika Bopanna is a Research Assistant; and Vrinda Datta is a Professor with the Centre for Human Ecology, Tata Institute of Social Sciences, Mumbai. Samir Dalwai is a Developmental Pediatrician and Director; Sohini Chatterjee is a Clinical Psychologist and Clinical Director; and Nita Mehta is a Clinical Psychologist and Research Co-ordinator with the New Horizons Child Development Centre, Mumbai.

INTRODUCTIONEpidemiological data on childhood developmental and psychological disorders in India have been abysmally minimal despite 14 percent of the global burden of disease being attributed to neuropsychiatric disorders in children (Prince and others, 2007). While there is a growing focus on child

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development with increasing literature on the importance of early brain development and early identification and intervention of developmental problems, there is limited reliable data on both trends in diagnosis and management of developmental problems in children. The prevalence of developmental disorders has been reported to be between 5 percent to 20 percent in children (Ali, Balaji, Dhaded and Goudar, 2011). It has also been recently estimated that in developing nations, about 39 percent of children below the age of five are not reaching their developmental potential because of poverty, malnutrition, high rates of infection, lack of stimulation and education and instability in the home.

In the light of the growing prevalence rates for childhood developmental and psychological disorders globally, the present study was conceptualised to provide an understanding to the trends in diagnosis and interventions in India by analysing the presentation of and interventions within a child development centre (CDC) in Mumbai. The study also aims to counter the lack of research in the area and suggest effective implications for the same.

Child Mental Health in IndiaChild and adolescent mental health (CAMH) has been defined as “... the capacity to achieve and maintain optimal psychological functioning and well-being” (World Health Organization, 2005: 7) and has been directly related to the child’s psychological and social functioning (Patel, Flisher, Nikapota and Malhotra, 2008). The child’s mental ill-health, on the other hand, is about the inability of a child to reach the optimum level of competence and functioning due to various developmental and psychological disorders. According to the UNESCO report (UNDP Report, 2008 as cited in Shastri, 2009: 89), ten percent of 5–15 year olds in India have a diagnosable mental health disorder and around 90 percent of children with a mental health disorder are not currently receiving any specialist service.

Available Interventions in IndiaMental health problems in children have been found to be associated with educational failure, family disruption and disability (Sawyer, 2000). If left untreated, mental health problems in children can create severe distress in children and their families (Shastri, 2009). While there is now growing evidence that indicates the effectiveness of interventions to improve children’s resilience, promote mental health and treat mental health problems and disorders (Shastri, 2009), there is a vast gap between child mental health needs (as measured through burden of disease estimates) and the availability of resources.

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Mental Health Research in IndiaThere are very limited specialised child mental health services in India (Shastri, 2009) and there is much less documented about the service. Mental health research in low and middle income countries contribute barely 3–6percent of all published mental health research in the world (Patel and Sumathipala, 2001; Saxena, Paraje, Sharan, Karam, and Sadana, 2006) and the evidence base for affordable and effective interventions for promotion and prevention is also very limited (Patel, Flisher, Nikapota and Malhotra, 2008).

METHODOLOGYIdentifying the lack of data on childhood developmental and psychological disorders in India, along with minimally documented data about interventions for the same, the aim of the study was to determine the trends in diagnosis of childhood developmental and psychological disorders in a population of children attending a child development centre. The study also focused on determining the role of specific interventions for childhood developmental and psychological disorders in India with a focus on multidisciplinary approach.

MethodsFor the present study, a mixed methods study with an exploratory sequential design was employed.

Phase 1 was a quantitative study which was followed by phase 2, a qualitative study. As Morse (1998) explains, the second phase is the qualitative phase; this was implemented as a follow-up approach to the quantitative data for the purpose of explaining the results.

Sample SiteThe sample for the study was obtained from New Horizons Child Development Centre (NHCDC). NHCDC is one of the largest multidisciplinary, comprehensive and integrated child development centres in India. Founded in 2003 and with centres across Mumbai, NHCDC offers services under one roof through a multi-disciplinary team comprising a Developmental Pediatrician, Clinical and Counselling Psychologists, Occupational Therapists, Physical Therapists, Remedial Educators, Speech Therapists and a Nutritionist. NHCDC’s philosophy is ‘From Label to Enable’ by understanding strengths and challenges of every child and offering Intervention Programmes to children and their families.


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Data Collection

Phase 1: Quantitative Data

For the quantitative study, a secondary data analysis was conducted with documented cases of children who visited the CDC between the years 2009 to 2012. Of these, only 1,301 children with complete case records were included in the study.

With reference to the case reports, an exhaustive code book with all the change indicators on which the children were assessed by the practitioners in the multi-disciplinary team, was created. The code book covered demographic details, and covered each intervention offered in the CDC, namely, Occupational Therapy (OT), Remedial Education (RE), Speech and Language Therapy (SL), Physiotherapy (PT) and Clinical and Counselling Psychology services. This code sheet was audited by the research and the CDC team to ensure all change indicators assessed on the case report were included accurately.

Phase 2: Qualitative DataThe qualitative study was included in the research as a follow-up to the quantitative findings, and to give voice to the stakeholders in the process—organisation heads, therapists and parents.

For the qualitative study, four in-depth interview guides were prepared by the research team: one each for parents, the therapists, the developmental paediatrician and director of the CDC, and the clinical coordinator of the CDC, respectively.

Ethical ConsiderationsIdentification codes were used to maintain the anonymity of the clients and all research information was kept confidential. For the interviews, informed consent was obtained from all participants.

Data Analysis

Quantitative analysisA secondary data analysis was conducted for the quantitative data. The collected 1,301 case reports of children were coded and entered into SPSS 20 for further analysis. Analysis was done using descriptive statistics and cross tabs to ascertain associations.


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Qualitative analysisThe data obtained through the in-depth interviews with the stakeholders were thematically analysed.

RESULTS AND ANALYSISThe present study aimed to understand the trends in diagnosis of and interventions in childhood developmental and psychological disorders.

Participant Profile

Phase 1The sample for the quantitative phase of the study consisted of 1,301 children who visited the sample site between the years 2009–2012 and for whom the complete case records were available. These children followed the organisational process in the CDC; they first met with the developmental paediatrician and were then referred for a combination of interventions as deemed necessary. The children went through a preliminary evaluation, followed by subsequent re-evaluations every 6 to 12 months as required. Each evaluation was completed by an internal discussion that resulted in a comprehensive document with recommendations.

The following tables elaborate on the sample profile.

Table 1: Details of Sample across the Years in Terms of Number of Children and Mean Age for both Boys and Girls

Year Boys Mean Age (Boys)

Girls Mean Age (Girls)

Total

2009 239 7.14 69 7.33 3082010 218 5.99 88 5.89 3062011 261 6.45 106 6.75 3672012 219 7.03 101 6.58 320Total 937 – 364 – 1301

The numbers in Table 1 clearly show that the help-seeking for boys is much higher than that of girls. Evidently, the number of childhood problems among boys is much higher than girls. These numbers could be understood in a socio-cultural context too, where the help-seeking for boys is greater due to the existing gender bias in a patriarchal society. This gap in numbers between genders highlights the importance of exploring further gender differences in the prevalence and help-seeking trends of childhood disorders.


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Table 1 reveals that the mean age of children seeking help was above six years of age. It is manifest in these findings that children are reaching out to health services much later than they should. In the interviews conducted, parents explain that the child’s problem is not felt to be a serious issue until much later in the child’s life. Two parents also spoke about how their relatives and friends suggest that the problem will pass when the child grows up. One set of parents, who had sent their child for an early intervention, also spoke about being discouraged by their friends saying that the intervention was unnecessary.

Delay in seeking help is a common issue faced by practitioners as it is seen that parents ignore or look towards more informal ways of dealing with the issue before they address the concerns in a formal setting with specialised services. In such cases then, the child’s concerns are aggravated and impact the outcome and prognosis. Ho and Chung (1995) characterise the help-seeking process among child psychiatric clinic attendees by (1) a sequential pattern of lay consultations starting from the families, relatives, friends, and neighbours; (2) detour via multiple professionals; (3) delay in reaching specialist services (Ho and Y, Help-Seeking behaviours among child psychiatric clinic attenders in Hong Kong, 1996).

Table 2: Number of Children Receiving Interventions at the CDC

Reports 1st Evalua-

tion

1st Revalua-

tion

2nd Revalua-

tion

3rd Revalua-

tion

4th Revalua-

tion

Demographic/Case history 1301 – – – –

OT 1072 96 14 5 1

Remedial 573 36 4 – –

Speech 503 12 – – –

Physiotherapy 175 4 – – –

Each revaluation was done in a period of 6 to 12 months, as required. As numbers indicate in Table 2, it is evident that therapy follow-up is poor. Effective documentation is seen to enable a better compliance rate even after a gap in therapy; however, it remains a huge struggle in India, along with high drop-out rates for therapy. In such cases, it becomes challenging to effectively cater to the child’s issues and hand-hold them till they are able to function effectively.


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Table 3: Highlighting School Attendance and Type of School Attended by the Sample

Type of School Gender TotalBoys Girls

Regular 744 281 1,025Special 13 3 16National Institute of Open Schooling 3 1 4Total 760 285 1,045

Out of the total sample of 1,301 children, 1,025 were attending regular schools, 16 were attending Special Schools, and 4 were studying from the National Institute of Open Schooling. Thus, the total number of children receiving formal education was 1,045 (Table 3).

Of the remaining 256 children, data was unavailable for 57 children. Of the 199 children who were not attending school, 57 were above 5 years of age. The remaining164 children were not of school going age.

Phase 2The sample for the qualitative phase of the study was focused on gaining in-depth inputs from the stakeholders in the functioning of the CDC. These included organisational heads, therapists and parents of children who were utilising a particular intervention service in the organisation. Since the organisation’s basic premise is to be multidisciplinary in its approach, the sample also included the parents of a child who was receiving multiple therapeutic interventions in the CDC.

The following table provides an overview of the stakeholders interviewed.

Table 4: Stakeholders Interviewed

Director 1Clinical Coordinator 1Developmental pediatrician 1Intervention Therapists Primary CaregiverOccupational therapy 2 1Physiotherapy 1 1Speech and Language Therapy 2 1Psychotherapy 2 1Remedial Education 2 1Multidisciplinary - 1


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The subsequent results will be divided in two sections—Disorders and Interventions. The section on disorders will cover data tabulated in terms of disorder wise specifications and presentations of the same. Following this, the section on Interventions will provide an understanding of the kind of disorders referred for each therapy in the CDC and the effectiveness of the same in terms of a pre and post analysis.

DISORDERS

Syndromal DisordersSyndromal disorders are those which meet all the criteria for a particular disorder. A syndrome disorder is the collection of signs and symptoms that are observed in and are characteristic of a particular condition.

The following tables provide details of the diagnoses for each syndromal disorder. It is important to mention here, that though the total number of children for the quantitative study was 1,301, many of them received more than one diagnosis. Hence, in the following tables, the number of children for each disorder has been calculated separately.

Table 5: Distribution of Children across Syndromal Disorders

Disorder Number of Cases

Percentage in Sample (N=1301)

Intellectual Disability 226 17.4Delayed Speech Milestone 397 30.5Delayed Motor Milestone 249 19.13Delayed Language 442 33.9Specific Learning Disorder 116 8.9Autistic Disorder 124 9.5Retts Syndrome 1 0.1Aspergers 5 0.4Pervasive Developmental Disorder—not otherwise specified

15 1.2

Attention-Deficit/Hyperactivity Disorder 422 32.4Oppositional Defiant Disorder 47 3.6Conduct Disorder 8 0.6

Upon analysis, it was seen that Attention-Deficit/Hyperactivity Disorder (ADHD) was the most commonly diagnosed disorder. Four hundred and twenty-two (32.4percent) children were diagnosed with


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ADHD. The prevalence of ADHD has been found to be high amongst children in India. In a study done by Venkata and Panicker (2013), it was seen that 11.32 percent of primary school children (6–11 years) had the presence of ADHD (Venkata and Panicker, 2013). Due to ADHD being one of the most common childhood onset psychiatric disorders, another Indian research conducted by Suvarna and Kamath (2009) in South West Mumbai aimed to determine the prevalence rate of ADHD in preschool age children. This study found that out of the 1,250 children assessed (599 boys and 651 girls), 152 (12.2 percent) children were diagnosed to have ADHD (Suvarna and Kamath, 2009).

Even though the presented results do purport that ADHD is the most commonly diagnosed disorder, individuals from the field of mental health research and practice express concerns over the overdiagnosis of the disorder. As cited by Mota-castillo (2007) in the Psychiatric Times, few causative factors for overdiagnosis might be misconstruing behaviours as causative explanations of the disorder, failure to obtain a complete family history, and cultural and linguistic barriers while dealing with the client. Further, failure to use standardised scales/tools for diagnosis might also contribute to the same.

It was also found that 226 (17.4 percent) children were diagnosed with Intellectual Disability (ID). Current literature also supports a high prevalence rate for ID. A study done by Bhagya and Ramakrishna (2013) stated that rural Mangalore had a prevalence of 3 per 1000 children whereas urban areas had a prevalence rate of 5 per 1000 (Bhagya and Ramakrishna, 2013). Even in Kerala, in a random sample of 1,403 children aged 8 to 12 years, a projected prevalence of 9.4 percent for ID was found (Hackett, Hackett, Bhakta, and Gowers, 1999).

From the sample, 116 (8.9 percent) had been diagnosed with a Specific Learning Disability (SLD). Estimates on the prevalence of learning disabilities range from 2 to 10 percent (Arun, Chavan, Bhargava, Sharma, and Kaur, 2013). The prevalence study on learning disability conducted at the L.T.M.G. Hospital, Sion, Mumbai revealed that of the total number of 2,225 children visiting the hospital for certification of any kind of disability, 640 were diagnosed as having a SLD. (LTMG, 2006)

124 (9.5percent) of the children exhibited clinically significant symptoms of Autistic Disorder. India is home to about 10 million people with autistic disorder and the disability has shown an increase over the last few years. According to statistics by the Centre for Disease Control and


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Prevention (CDC), one in every 88 children today is born with an autism spectrum disorder (ASD) against a ratio of one in 110 few years back (Uttam, 2012).

This section on Syndromal disorders depicts the trends in diagnosis of childhood developmental and psychological disorders among children seeking help in a CDC. As seen in the results, ADHD is the most commonly diagnosed disorder followed by ID, SLD and Autistic Disorder. As mentioned previously, each disorder has been analysed categorically to account for the overlaps due to multiple diagnoses.

Sub-syndromal DisordersIt was increasingly observed in the case reports that even though children were not receiving a diagnosis, their symptoms were seen as significant and needing intervention. Further, in cases where children had received a diagnosis too, other symptoms were reported which were not significant to obtain a diagnosis.

The following table details the sub-syndromal presentations analysed and the number of children who were reported as exhibiting the same. It is important to mention here, that many of the children are showing more than one sub-syndromal presentation, and have been coded as per each presentation separately.

Table 6: Distribution of Children across Sub-Syndromal Disorders

Disorder Number of Cases

Percentage in Sample (N=1301)

Speech Concerns 21 1.6

Motor Concerns 9 0.7

Subnormal Developmental Quotient 337 25.9

Autism Spectrum Features 75 5.8

Learning Difficulties 340 26.1

Hyperactivity 273 21

Inattention 287 22

Impulsivity 126 9.7

Behavioural Symptoms 433 33.3

Emotional Difficulties 251 19.3

Difficulties in Interpersonal Relations 32 2.5

Lack of Stimulation 10 0.8


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Four hundred and thirty-three (33.3 percent) children were seen as exhibiting behavioural symptoms. These behavioural symptoms constituted behavioural issues such as aggressiveness and conduct difficulties not amounting to a diagnosis.

Numbers were also seen to be high for Subnormal Developmental Quotient (337 children, 25.9 percent) and Learning Disability (340 children, 26.1 percent). This was followed by hyperactivity (273 children, 21 percent) and inattention (287 children, 22 percent) and finally emotional symptoms (251 children, 19.3 percent).

The section on sub-syndromal disorders supports two recommendations — first, that a diagnosis of a specific disorder is not necessary for initiating a therapeutic intervention and second, co-morbidities almost always exist. This is explored further in the next sub-section.

Co-morbidityThe study revealed that children were diagnosed for more than one disorder, or there were associations present between syndrome and sub-syndromal disorders.

The following sections elaborate on these co–morbidities.

Co–morbidities between two Syndromal Disorders

Table 7: Highest Levels of Co-morbidity between Syndromal Disorders in the Sample

Disorder 1 Disorder 2 Total Number of Cases

Co-morbid Cases

Percentage of Co-morbidity

Autism Delay in Language

566 79 13.9

ID ADHD 648 77 11.88

ADHD ODD 469 32 6.82

In the present research, 79 (13.9 percent) of the participants who were diagnosed with autism, had a delay in language development. A study done by Kjelgaard and Tager-Flusberg (2001) presented findings which showed language skills as significantly below age expectations in children with autism (Kjelgaarda and Tager-Flusbergb, 2001). Although as seen in the data, not every child with autism is affected by communication difficulties; however, a child’s ability to communicate varies depending on his/ her intellectual and social development. Even though most children


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with autism have little or no problem in pronouncing words, the majority have difficulties in utilising language effectively (NIDCD, 2010).

A co-morbidity of ID and ADHD was present among 77 (11.88 percent) children. Existing research suggests that children with intellectual disabilities are at an increased risk for ADHD, and that the symptoms might successfully be treated with stimulant drugs (Hastings, Beck, Daley, and Hill, 2005). Further, a study done with 140 children using psychiatric and intellectual assessments found that the ADHD children did worse on scales of IQ such as Wechsler Intelligence Scale for Children—Revised (Faraone and others, 1993). A review of literature done by Reilly and Holland (2011) found that reported prevalence rates of ADHD symptoms in individuals with intellectual disability vary significantly due to the instruments and diagnostic practices employed. Despite the prevalence, existing data on the said co-morbidity is very minimal and needs to be clarified on an urgent basis (Hastings, Beck, Daley, and Hill, 2005; Reilly and Holland, 2011).

Out of the total children who had ADHD and ODD, 32 (0.8percent) children presented a co-morbidity between the two disorders. A study done by Girimaji and others (2011) found ADHD to be the commonest co-morbid condition in a sample with 10 children. Literature strongly purports the prevalence of co-morbidity between ADHD and ODD (Table 7). A study conducted by Elia, Ambrosini and Berrettini (2008) found 139 children (40.6 percent of the sample) exhibited an ADHD and ODD co–morbidity. Similarly, a four year follow-up study done by Bierderman and others (1996) found that 65 percent of the children in his sample had a co–morbid presentation of ODD and ADHD (Biederman and others, 1996).

Co–morbidities between a Syndromal Disorder and a Sub–syndromal Disorder

Table 8: Highest Levels of Comorbidity between a Syndromal Disorder and a Sub–syndromal Disorder

Syndromal Sub-syndromal Total Number of Cases

Co-morbid Cases

Percentage of Cases

IDBehavioural symptoms 659 67 10.16Emotional symptoms 477 42 8.8

LDEmotional symptoms 367 44 11.98Hyperactivity 389 17 4.37Inattention 403 22 5.45

ADHD Emotional symptoms 673 86 12.77


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ID with Subsyndromal DisordersIn the present sample, 67 (10.16 percent) children with ID also had sub-syndromal behavioural symptoms and 42 (8.8 percent) children diagnosed with ID were seen to be displaying significant emotional symptoms. Behavioural symptoms include significant displays of aggressiveness, conduct difficulties, and so on, whereas emotional symptoms comprised unconstructive emotional reactions, dull mood and so on. Behavioural issues are frequent in children with an intellectual disability. The prevalence rate of psychiatric disturbances in children with an ID is 20 percent to 35 percent, three to five times higher than that for the general population (Ageranioti-Belanger and others, 2012). This can be linked to the findings in the syndromal cases too, as ID was found to be co-morbid with ADHD. Forster and others (2011) found behavioural and emotional problems in people with intellectual disabilities (Forster and others, 2011). Behavioural symptomatology is usually found to be remarkably persistent particularly stereotypy, emotional abnormalities, eye-avoidance and overactivity (Thompson, 2002).

LD with Subsyndromal DisordersThe present sample indicates co–morbid presentations between LD and emotional symptoms. Forty-four (11.98percent) children are seen as presenting a co–morbidity between LD and emotional symptoms. As noted by Arthur (2003), emotional issues of individuals with learning difficulties have been largely neglected. Now, however, emotional difficulties are given importance and are seen to be benefitted by psychological techniques. There is evidence to suggest that people with learning disability experience problems recognising emotions of others through facial expressions, find it hard to cope with high intensity emotions and experience difficulty in managing emotionally arousing situations (Gray, Fraser and Leudar, 1983).

Learning and behavioural problems such as hyperactivity and inattention are common in children with clinically significant symptoms as they are related brain processes (Miller, 2012). In the present sample 17 (4.37 percent) children with learning disabilities had hyperactive symptoms and 22 (5.45 percent) children with learning disabilities had inattention symptoms.

ADHD and Sub-syndromal DisordersInterestingly, syndromal ADHD also has a high rate of co-morbidity with sub-syndromal LD in the present sample. One hundred sixty-nine


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(22.17 percent) children who were diagnosed with ADHD were noted as experiencing problems with learning. Also, 86 (12.77 percent) of the children diagnosed with ADHD exhibited emotional issues.

The section on co-morbidity strongly highlights the need to pay heed to the complexity in presentations of childhood problems. Findings of the study suggest that the syndromal disorders are co–morbid with syndromal as well as sub-syndromal disorders. This provides important implications for interventions in childhood problems. Considering that there is an overlap between developmental and psychological problems and children present with varied co-morbid conditions, interventions need to be comprehensive and individualised requiring a multidisciplinary approach, where professionals with specialised training come together to respond to the needs of the child.

INTERVENTIONSThis section will analyse each intervention at the CDC separately. The interventions include: Occupational Therapy (OT), Physiotherapy (PT), Remedial Education (RE) and Speech and Language Therapy (SL). Each intervention will be looked at in terms of association with the disorders, participant profiles and a pre and post assessment of the change indicators. In the CDC, the child is first assessed by the developmental pediatrician, who then refers the child for an Individualised Therapy Plan (ITP). This ITP is a combination of therapies offered at the CDC, as per the child’s specific needs. In addition to these therapies, children requiring emotional support also availed psychotherapeutic interventions.

Occupational Therapy (OT)Occupational Therapy is the use of treatments to develop, recover or maintain the daily living and work skills of patients with a physical, mental or developmental condition. It enables a child to perform his/her daily activities with developmental skills and, uses play and other activities in a structured and scientifically proficient way to achieve his/her potential.

From the total number of children who sought help in the CDC, 1,072 were referred further for Occupational Therapy and underwent baseline OT assessment. Of these, 96 were reassessed after completing 6 months of OT, 14 were reassessed after another 6 months, 5 were reassessed in the next 6 months and 1 attended a 4th re-evaluation after another 6 months.

The following table shows the types of syndromal disorders referred to the OT centre.


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As evident from Table 9, children from almost all the diagnosed disorders were referred for OT. Thus, these findings confirm the fact that even though theoretically the child may not require OT intervention, the inherent co-morbid presentations in the disorder require OT.

Table 9: Number of Children Diagnosed with a Disorder and Referred for Occupational Therapy

Disorder Total Number of

Cases

Number of Cases

Referred for Occupational

Therapy

Percentage

Intellectual Disability 226 188 83.18

Delayed Speech Milestone 397 340 86.64

Delayed Motor Milestone 248 214 85.94

Delayed Language Milestone 442 375 84.84

Specific Learning Disability 116 101 87.06

Autistic Disorder 124 110 88.70

Aspergers 5 3 60

Pervasive Developmental Disorder-not otherwise specified

15 13 86.66

Attention-Deficit/Hyperactivity Disorder

422 350 82.93

Oppositional Defiant Disorder 47 42 89.36

Conduct Disorder 8 8 100

Down Syndrome 15 13 86.66

Cerebral Palsy 9 8 88.88

Further analysis revealed that in 2009, the maximum cases referred for OT were in the age group of 3–6 years, 6–9 years in 2010, 3–6 years in 2011, and 6–9 years in 2012.

Pre and Post AssessmentWhen the change indicators of Occupational Therapy were analysed (Table 10), it was seen that the highest change occurred in fine motor skills (79.38 percent children in therapy showed improvement), restlessness (69.79 percent children in therapy showed improvement), hyperactivity (improvement in 56.25 percent children in OT) and frustration tolerance (46.15 percent children in OT showed improvement).


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The least percentage of change for the children in OT was in toe-walking (none of the 94 children showed improvement) and stereotypical behaviour (only 2.10 percent of the children in therapy showed improvement).

Table 10: Year wise Specifications of Number of Children Referred for Occupational therapy

Year Boys Girls Total

2009 200 54 254

2010 191 75 266

2011 223 85 308

2012 176 68 244

Total 790 282 1072

Physiotherapy (PT)Physiotherapy (PT) involves remediation of impairments and disabilities and the promotion of mobility, functional ability, quality of life and movement potential. A physiotherapist works with children with motor difficulties, neurological conditions and development delays. PT works best in people having impairment in gross motor skills such as walking, hand movements, people with balance issues, strength and coordination issues, and cerebral palsy, among others.

From the total sample of 1,301, 175 children were referred for a physiotherapy evaluation and 4 were reassessed after 6 months.

It is seen in Table 11 that not all the children diagnosed with Cerebral Palsy (CP) availed PT services, even though PT was recommended.

Further analysis revealed that the highest number of children referred for PT across all the years were in the age group of 3–6 years (Table 12).

Pre and post AssessmentThe pre and post associations between the change indicators in physiotherapy indicated that positive change in the present sample was seen in dynamic sitting (75 percent of the children assessed showed improvement) and oromotor (25 percent of the children assessed showed improvement).


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Table 11: Number of Children Diagnosed with a Disorder and referred for Physiotherapy

Disorder Total Number of

Cases

Number of Cases referred for

Physiotherapy

Percentage







Pervasive Developmental Disorder – not otherwise specified

15 3 20


422 53 12.55




Minimal change was observed in higher order abilities of gross motor functions, fine motor abilities, musculoskeletal system and skeletal system. These included change indicators such as squatting, eye-leg coordination, somatosensory system, and so on.

As the children referred for PT were high in the age group of 3–6 years, it is possible that the developmentally complex functions were not assessed, as this was not required for their age.

Table 12: Year wise Specifications of Children Referred for Physiotherapy

Year Boys Girls Total

2009 24 9 33

2010 31 11 42

2011 39 16 55

2012 19 26 45

Total 113 62 175


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Remedial EducationOf the 1,301 children, 573 children were referred for Remedial Education (RE). Of these, 36 were reassessed after 6 months and 4 were assessed again after another 6 months (Table 13).

Table 13: Number of Children Diagnosed with a Disorder and Referred for Remedial Education

Disorder N Number of Cases

Referred RE

Percentage







Aspergers 5 4 80

Pervasive Developmental Disorder- not otherwise specified

15 9 60


422 189 44.78


Conduct Disorder 8 3 37.5



Pre and Post AssessmentThe pre and post assessment of RE highlighted that positive change was seen in expression (63.63 percent of the children in therapy showed improvement), fluency (58.8 percent of the children in therapy showed improvement) and sentence formation (46 percent children in therapy showed improvement).

Further analysis of data for the maximum number of referrals for RE across the years revealed that in 2009, most children belonged to the age group of 9–12 years, the age group of 6–9 years in 2010, the age group of 9–12 years in 2011, and the age group of 12–15 years in 2012 (Table 14).


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Table 14: Year wise Specifications of Children Referred for Remedial Edu-cation

Year Boys Girls Total2009 114 30 1442010 101 43 1442011 99 50 1492012 98 38 136Total 412 161 573

In comparison, change indicators which showed a lesser amount of change were formation of letters in essay writing (39.13 percent children showed improvement) and comprehension in word problems (35 percent showed improvement).

Speech and Language Therapy Out of the total sample of 1,301 children, 503 were referred for Speech and Language Therapy, and 12 were reassessed after a period of 6 months.

Table 15: Number of Children Diagnosed with a Disorder and Referred for SL

Disorder Number Number of Cases

referred for Speech and Language Therapy

Percentage

Intellectual Disability 226 67 29.64Delayed Speech Milestone 397 156 39.29Delayed Motor Milestone 248 82 33.06Delayed Language Milestone 442 174 39.36Specific Learning Disability 116 44 37.93Autistic Disorder 124 52 41.93Aspergers 5 2 40Pervasive Developmental Disorder-not otherwise specified

15 8 53.33


422 166 39.33

Oppositional Defiant Disorder 47 20 42.55Conduct Disorder 8 3 37.5Down Syndrome 15 5 33.33Cerebral Palsy 9 4 44.44


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Upon further analysis, it was seen that the highest number of children referred for Speech and Language therapy were in the age bracket of 3–6 years.

Pre and Post AssessmentThe pre and post assessment for Speech and Language Therapy showed that the most positive change was identified in the change indicator of echolalia (63.63 percent of the children in therapy showed improvement) and cooperative play (41.66 percent). On the other hand, minimal amount of change was identified in Level of Response to the activities in therapy (only 25 percent showed improvement) and Social Smile (only 33.33 percent children showed improvement).

Table 16: Year wise Specifications for Children referred to Speech and Language Therapy

Year Boys Girls Total2009 87 21 1082010 104 35 1392011 113 36 1492012 74 33 107Total 378 125 503

DISCUSSIONResearch strongly points to the increase in prevalence rates for childhood developmental and psychological disorders in India and also ascertains the lack of available interventions for the same. The present study was conceptualised to provide an understanding of the trends in diagnosis of childhood developmental and psychological disorders in a child development centre in Mumbai, and also cover the demand and supply gap by assessing the effectiveness of a multidisciplinary intervention programme. Thus, the present study aims to contribute to the minimal amount of mental health research available for childhood developmental and psychological problems in India. The study provides important implications for practice, research, training and policy changes.

The study was conducted in two phases: Phase 1 was a quantitative analysis of coded case reports of 1,301 children obtained from the CDC records available from 2009–2012, and Phase 2 was a thematic analysis of in-depth interviews conducted with stakeholders in the CDC.


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The multidisciplinary child development centre included in the study provided a variety of interventions: occupational therapy (OT), physiotherapy (PT), psychotherapy, remedial education (RE) and speech and language therapy, within an integrated and comprehensive framework. In this particular CDC, the child is first seen by the developmental pediatrician, who then refers the child for an individualised therapy plan. Each therapeutic department thereafter follows this Individualised Therapy Programme (ITP) for the child.

The study highlighted some important points.

Co-morbidities and Specialised InterventionsA crucial finding of the study was regarding the complexity of presentations in childhood problems. The analysis strongly pointed to the fact that disorders do not always exist or present themselves categorically; however, there are further sub-syndromal and co-morbid presentations of a childhood problem. For example, 433 children were not clinically diagnosed for a behavioural disorder, but were reported as exhibiting significant behavioural symptoms warranting interventions.

The developmental pediatrician and director of the CDC explained that due to these complexities in presentation, the CDC follows an intervention pattern which caters to each child and his/ her problem separately. This ITP is designed to help children move beyond their problem and achieve their highest potential. The importance of understanding the co-morbidities presenting in the clients and dealing with it through an ITP was mentioned by most of the practitioners interviewed. As expressed by a speech therapist in the CDC, in the case of a child with autism and a speech delay, the child is first recommended for OT, so that he is better prepared to receive speech therapy.

Multidisciplinary Expertise for Complex PresentationsThe study strongly recommends a multidisciplinary approach for co-morbid presentations as the most beneficial for childhood problems. Each therapy caters to a particular need of a client that requires specific inputs from a trained specialist. For example, a speech and language therapist specialises in the evaluation and treatment of speech and language disorders whereas an occupational therapist aims to achieve functional outcomes to develop, sustain and retain the highest possible level of independence.


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The in-depth interviews conducted with the therapists revealed that the multidisciplinary set up enables them to increase their therapeutic effectiveness. The ITP driven approach prevents repetition and avoids omission of interventions. Therapists also say that a multidisciplinary programme is beneficial for the clients and that parents are included and kept informed about each therapeutic process used for their child.

Although parents expressed initial confusion and reluctance towards the therapeutic processes, they were later convinced about the benefits of ‘many therapies under one roof’. Parents also appreciated the emotional and mental support provided by the therapists and psychologists when they felt ‘they were going to give up’. Observing the team taking their child through the therapy process and experiencing the consequent benefits strengthened their resolve to continue the multidisciplinary therapeutic process.

Coordination between TherapistsCoordination between therapists is essential for the holistic development of the child, which according to the director of the CDC can be viewed as two fold — functionality and logistics. He explains this further: for example, in an individualised therapy set up, the practitioner is responsible for only the one hour allotted for practice/therapy, which would in effect be insufficient and therefore unfair to the child. On the other hand, a team of therapists who function or operate in one centre, know exactly what each therapist is doing as the goal is clear. Logistically, parents do not have to go to multiple centres for their child.

In the light of these results, the implications are organised under the following headings.

Practice

Multidisciplinary Practice for Childhood Developmental and Psychological ProblemsConsidering the complexities in presentations of disorders, it is evident that a multidisciplinary set up is advantageous for childhood disorders. Every child in the centre is referred for more than one therapy if needed, along with parental counselling services for the caregivers, thus ensuring a holistic form of intervention for the client and his/her family.


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Training

The Importance of Understanding Sub-Syndromal and Co-morbid PresentationsAlthough the clients were diagnosed with a particular disorder, many showed presentations of other disorders, which were not effective for a diagnosis, but were still significant and needed to be reported. Further, many co-morbid presentations were also observed.

This process threw light on the complexity of presentations in childhood developmental and psychological disorders. It is important to identify that the presentation varies with age and disorders do not present themselves in a singular form; the practitioner therefore needs to identify and deal with further presentations in the course of therapy.

Presently, training programmes offer a point based identification process for therapists in training. Hence, training programmes should be oriented towards equipping the trainees to identify complexities in a childhood disorder and how to deal with a complex presentation.

ResearchAs identified earlier, the output of mental health research in developing countries is very low. This study proves to be an impetus for research in the area of childhood developmental and psychological disorders.

Interventions in India need to be understood through outcome studies to assess their effectiveness for childhood disorders. This data is essential to promote evidence based practice for childhood disorders in the country. Further, a multidisciplinary intervention provides greater scope for long term assessment of cases and research.

Policy ChangesThis study also provides evidence for suggested policy level changes in India. The replication of the multidisciplinary intervention approach as a standard practice model is recommended especially, as there is visible overlap of the developmental and psychological issues when dealing with childhood disorders.


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