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