1 Prof.Roseline WEEK-3 Languages, Dialects & Varieties LECTURE - 3.
Child Psychiatry & Training in India Current Status and ...Diversity India is secular with various...
Transcript of Child Psychiatry & Training in India Current Status and ...Diversity India is secular with various...
Child Psychiatry & Training in India
Current Status and Future Possibilities
Dr PORPAVAI KASIANNAN
THE CHALLENGE
Indian Situation
Unique in terms of it’s large population:
1,363,416,218 as of Wednesday, February 20, 2019,
based on the latest United Nations estimates.
India population is equivalent to 17.74% of the total
world’s population.
Around 50 % are children and adolescents.
Median age is 27 years.
33.6% Urban and 66.4% Rural
Children in India
Not a homogenous population
Large number have no home, no school and no family
Children under 0-14year age who are orphans, approximately 6.8% (25 million, UNICEF 2007) probably more now; Over 11 million abandoned babies, 90% girls; one list has around 900 orphanages listed
Does not include destitute homes, beggars' homes, juvenile homes, rescue homes, and remand homes and street children ( more than 18 million)
Around 20% of children have borderline intellectual functioning, learning, speech, visual and hearing impairments
Largest population of married children under the age of 14- unique problems
90% of children in India have poor quality of life
Diversity
India is secular with various languages, cultures, and
religions.
It has 179 languages, 544 dialects, and 1942 mother
tongues; with 148 mediums of instruction at school level.
It has 29 states, 7 union territories and 719 districts
Each district is unique in a number of ways
This kind of complex and multifaceted country makes
formulation of national policies, programming, and
planning very difficult.
In the last Decade…
Changing structure of the family, modernization, westernization, industrialization, globalization, and urbanization have negatively influenced child mental health.
Incidences of mental health problems are on increase (278% increase in pedophilia).
Depression and suicide have increased three to four folds in large number of states in India.
Post-traumatic mental disorders have shown phenomenal rise. During this decade far more children have been killed and disabled than soldiers.
Mental health problems in children affected with riots, bomb blasts, and natural catastrophes are perpetually ever increasing in number.
Alcohol and other drug abuse in children have increased ten fold.
(WHO 2001)
Global Child and Adolescent Mental Health
Since 1977, the World Health Organization (WHO) has recommended promotion of child and adolescent mental health (CAMH)
Atlas: child and adolescent mental health services - WHO 2005 Countries with the largest proportion of children and adolescents are those that most lack specific CAMH policies, and lower-income, less developed countries have the fewest child and adolescent psychiatrists and other mental health professionals and the lowest availability of community mental health care.
More than 50% of countries are categorised as LAMI and CAMH issues are one of the most prevalent problems worldwide
Global Child and Adolescent Mental Health
Epidemiology: available evidence
◦ Mental disorders affect 10–20% of children and adolescents
worldwide
◦ Heterogeneity in prevalence studies prevents direct
comparisons between countries or meta-analytic approaches
◦ Risk factors for mental disorders identified in LMIC are similar
to those found in HIC; research on resilience is still scarce in
LMIC
Prevalence of Child and Adolescent Psychiatric
Disorders in India The ICMR study was carried out in Bangalore and Lucknow.
The sample was selected by stratified multistage sampling from middle class urban, urban slum and rural areas.
The results indicated a prevalence rate of 12.5 per cent among children aged 0-16 yr.
When impairment associated with the disorder was assessed, significant disability was found in 5.3 per cent of the 4-16 yr group.
Physical abuse and parental mental disorder were significantly associated with psychiatric disorders.
(Srinath S et al,2005)
Prevalence of Child and Adolescent Psychiatric
Disorders in India A systematic review and meta-analysis done in India in 2014
Sixteen community based studies on14594 children and adolescents; and seven school based studies on 5687 children and adolescents.
The prevalence rate of child and adolescent psychiatric disorders in the community was found to be 6.46% and in the school it was 23.33%
The study also found that the reporting systems of psychiatric disorders in children were inadequate
(Savita Malhotra and Bichitra Nanda Patra, 2014)
EVOLUTION OF CHILD PSYCHIATRY IN INDIA
Child Psychiatry in India
Child psychiatry has evolved over the years as a separate discipline that deals with psychological problems in the developmental phase of life from infancy through adolescence.
Initially started as child guidance clinics, now fully functional child and adolescent psychiatric departments have been setup in a number of reputed institutions all over the country.
There are about 20 specialized child and adolescent psychiatry clinics/departments in India.
Child and adolescent psychiatry is a newly emerging Subspecialty in India.
Child Psychiatry in India
The first Child Guidance Clinic(CGC) was established by
the Tata Institute of Social sciences, Mumbai in 1937
The CGC at NIMHANS started functioning since 1959
Since then until 2003 a total of 164 CGS mostly located
in large metropolitan cities managed by around 400
medical and other professionals with varied scope and
coverage.
In the1980’s there was a movement to develop CGC’s in
the community with multidisciplinary teams.
Child Psychiatry in India
There are only a handful of organised facilities for CAMH
Multidisciplinary CAP units have been established at NIMHANS, Bangalore,
AIIMS, New Delhi,
CMC Vellore
Niloufer Hospital, Hyderabad,
Central Institute of Psychiatry (CIP), Ranchi
Sanjay Gandhi Postgraduate Institute of Medical Sciences(SGPGI),Lucknow.
PGI , Chandigarh
And a number of small private concerns
Child Psychiatry in India
In the few general hospitals where CGC is available it is conducted once a week by psychiatrists who primarily provide services for adult patients. This results in lack of time for adequate evaluation and management of child psychiatric disorders.
In other settings CAP services are conducted in a Paediatric OPD by a Psychiatrist or a Psychologist attending as a visiting consultant and limiting themselves to handling the cases referred to them by the Paediatricians.
Specialization in Child Psychiatry
The need for specialization in Child and Adolescent
Psychiatry (CAP) was identified in 1979, in a workshop on
postgraduate training of Psychiatrists held at NIMHANS.
The idea of an association of child mental health
professionals originated in 1988 on the occasion of “National
Workshop on Child Mental Health: Needs and Priorities”
organized by, Department of Psychiatry, Chandigarh.
The Indian Association of Child and Adolescent Mental
health (IACAM) was formed and registered in 1991
Specialization in Child Psychiatry
The Indian Psychiatric Society (IPS) started a section on
CAP in the mid-1980s
IPS, in its General body meeting at Bhubaneswar in 2000,
endorsed the proposal made by NIMHANS for starting a
DM course in CAP .
PDF in CAP started in 2008, DM in CAP started in 2012
at NIMHANS
Training in Child and Adolescent Psychiatry
Training in child and adolescent psychiatry is not uniform across the postgraduate training facilities in India.
It ranges from no training in most places to 3 or 4 month training in certain centres
Most of the post-graduate training centres in the country do not address mental health issues of children and adolescents given the lack of proper infrastructure and faculty.
As part of their peripheral postings, CAP is at times ignored.
In the postgraduate examinations (theory and practical), very little emphasis is given to the evaluation and management of child and adolescent psychiatric disorders. This contributes to a lack of motivation in post-graduates to learn these aspects.
THE NEED
Areas of Primary Concern
Magnitude of the burden of child and adolescent mental disorders
World-wide up to 20% of children and adolescents suffer from a disabling mental illness (WHR, 2000).
Worldwide suicide is the 3rd leading cause of death among adolescents(WHR2001). Major depressive disorder (MDD) often has an onset in adolescence, across diverse countries, and is associated with substantial psycho- social impairment and risk of suicide (Weissman, 1999)
Conduct disorder related behaviours tend to persist into adolescence and adult life through drug abuse, juvenile delinquency, adult crime, antisocial behaviour, marital problems, poor employee relations, unemployment, interpersonal problems, and poor physical health
Only one out of the 100 gets some care and treatment. Around 90% of children with a mental health disorder are not currently receiving any specialist service.
It is high time we reach out to 90% of the child population that is being unattended by any agency
Treatment Facilities
There are very few centres in government sector with
exclusive in-patient treatment facilities.
There is a limited access to CAP services in smaller
towns and rural are
WHO guidelines, at least two child psychiatrists should
work full-time for each 60,000 children.
Huge gap between the need and available services for
mental health needs of children.
Current services in India
0.25 psychiatric beds per 10,000
0.4 psychiatrists per 100,000
0.03 psychologists per 100,000
0.03 social workers per 100,000
17.8 other medical practitioners per 100,000
0.05 psychiatric nurses per 100,000 (66.7 general nurses)
0.05 Community based IP units per 10,000
100% of OP facilities have some form of psychotropic medication
32% facilities provide psychosocial treatment
WHAT CAN BE DONE
Training
Creative training programs for a broad range of
previously trained paediatricians and adult psychiatrists
can add to the pool of child mental health trained
individuals at one end of the spectrum,
There is also the need to train larger numbers of
primary care workers, religious personnel, school
personnel, and community workers in basic child mental
health diagnosis and treatment methods.
Why train tier one/ primary care
sector?
Poor access to child mental health services to
children in need
Provision of mental health services are largely
restricted to curative services in tertiary care
facilities
Limited screening and early intervention
Limited psychosocial care provision by non-specialists
Rapid urbanization (displacement/ dislocation/
increasing psychosocial issues)
Services
Establishment of community-based child and adolescent
services.
Training and capacity building of childcare workers and
staff from various governmental and non-governmental
agencies, including schools.
Develop a comprehensive community child and
adolescent mental health service model that may be
replicated in all areas of the country.
NIMHANS child project, recently released
Mental Health Intervention
Spectrum for Mental Disorders
ROLE OF CAP GLOBAL VOLUNTEERS GROUP
Views from participants of Indian origin
Platform for rich exchange of ideas
Facilitate improvement in all aspects of child psychiatry in
diverse and resource limited settings, ranging from
training to community based delivery of services
Knowledge of contributions from members of group has
increased hope and take on new projects and
responsibilities that I would not have ventured otherwise
Shilpa Agarwal
Views from participants of Indian origin
CAP GP has a lot of promise
Provided opportunity to use the unique set of skills an understanding of the two systems and application at practical level
Communities are rapidly changing countries of origin with increased need for specialist input
This forum gives hope to create a platform where we can have a constant and consistent relationship which has so much of promise as the world becomes a global village
Soumya Basu
Views from participants of Indian origin
Helpful to meet like minded child psychiatrists who share
the vision of empowering professionals in improved
CAMH service in LAMI countries
This peer group with its collective diverse and extensive
experience helps to refine my thought process and helps
shape my efforts
Tejas Golhar
Views from participants of Indian origin
CAP GP group has fast tracked our work by giving it wings and direction
Presents opportunities to learn and collaborate with multiple players and at the same time refine the work that we are doing in our unique setting
The facilitation role played by Mindful (Paul and Sandra) has inspired creativity while keeping the interests of the developing countries in the forefront
Brave steps and hard work has occurred during this time. E.g. Porpavai’s work
Confidence in the strength of our collective abilities and has made us more determined to continue to learn and improve in this area.
Vibhay Raykar
Views from participants of Indian origin
It has been a great privilege to listen to, observe and experience the passion of all the members of the group
We share a common interest and passion to contribute to LMIC’s need for mental health support
We realized how resource poor and resource rich countries can have equal experiences to shar and enrich each other
The works of the Sri Lankan group and Porpavai have been inspirational to see what is possible even when a lot of odds are stacked against it.
This inspires us to learn and work together to develop novel ideas that fit with the human resource, social, cultural and economic realities of various countries
Sundar
Personal reflections
Being a part of CAP GP has played a big role in giving the last nudge to develop the work I was doing through Pathways Foundation in Coimbatore India, move forward
Helped me to gain confidence in starting the one year PG certificate course in CAMH
The new found friends through the group have been an immense support in taking the course forward by actively contributing in creative discussion and also by volunteering their time in teaching in the course
I step forward with renewed confidence in developing a community based clinical service in 2019