face-to-face (F2F) recruitment programme in 2018 with our first remote recruitment programme in 2... more face-to-face (F2F) recruitment programme in 2018 with our first remote recruitment programme in 2020. In a world of fast paced technology, we reflect on what lies in the horizon for international psychiatric recruitment. Method. The recruitment programme was organised by 4 psychiatric trainees affiliated to each mental health trust. A two-day remote programme on the Zoom platform comprising of 45-minute slots was created. Through their own experiences of inspirational speakers, trainees contacted speakers representing different specialities, teaching styles and philosophical outlooks. Pre and Post Programme questionnaires and certificates of attendance were shared with speakers and attendees. These were compared with Pre and Post Programme questionnaires from the F2F event in 2018. Result. When compared to the 2018 F2F programme, the 2020 virtual recruitment programme attracted a higher number and wider variety of applicants, in gender (62% female/38%male), nationality (UK 79%/Non-UK 22%), as well as wider distribution in age, UK deanery and training position. Despite the elimination of cost, the quality of teaching was rated higher than F2F due to the availability of high quality speakers (100% would recommend to a friend; 72% rated excellent). Whilst the programme was effective in changing minds, this did not exceed F2F recruitment rates. F2F recruitment feedback focussed on inclusion of subspecialities, whereas virtual programme feedback focussed on ways to enhance interaction. Feedback focussed on technological applications such as interactive quizzes, breakout rooms, play-acting, and having the benefit of clinical vignettes or speakers' personal stories to bring talks to life. Conclusion. The use of remote technology transcended geographical and demographic frontiers. A variety of high-quality speakers, directly appealing to an international cohort were sourced, at no monetary cost. In future, the budget will be used in interactive applications, and time-limited session recordings. As the participants hungered for personal connections, we recommend a blended programme, with links to taster sessions, retaining the advantages of both strategies.
Islamophobia is a fear of or prejudice towards Muslims which can affect both the adult and pediat... more Islamophobia is a fear of or prejudice towards Muslims which can affect both the adult and pediatric population. Exposure to racial discrimination or other forms of overt or covert prejudice during the stages of racial identity formation could lead to the development of Islamophobia in children and adolescents. Historical and current events in which Muslims are portrayed in a negative way in the media may also play an important role in the etiology of Islamophobia in this population. Exposure to Islamophobic elements may affect the process of identity formation in Muslim children and adolescents, leading to poor self-esteem and possibly mental health conditions later in life. Muslim children and adolescents are also at a greater risk of being victims of bullying and acts of aggression. These individuals may also develop impaired relationship with parents, peers, and society in general. Parents and clinicians have a significant role in helping these individuals. It is important to ha...
Background Screening for changes in pregnancy-related anxiety and depressive symptoms during preg... more Background Screening for changes in pregnancy-related anxiety and depressive symptoms during pregnancy may further our understanding of the relationship between these two variables and preterm birth. Objectives To determine whether changes in pregnancy-related anxiety and depressive symptoms during pregnancy influence the risk of preterm birth among Pakistani women; explore whether perceived stress moderates or mediates this relationship, and examine the relationship between the various components of pregnancy-related anxiety and preterm birth. Methods A prospective cohort study design was used to recruit a diverse sample of 300 low-risk pregnant women from four centers of Aga Khan Hospital for Women and Children in Karachi, Pakistan. Changes in pregnancy-related anxiety and depressive symptoms during pregnancy were tested. Multiple logistic regression analysis was used to determine a predictive model for preterm birth. We then determined if the influence of perceived stress could m...
Autism is a pervasive, neurodevelopmental disorder characterized by stereotyped movements and imp... more Autism is a pervasive, neurodevelopmental disorder characterized by stereotyped movements and impairment in social skills and communication patterns. Prevalence patterns show an increasing burden of about 1 in 150 children affected by the disorder. Most affected individuals have symptoms that interfere greatly with quality of life. Although a burgeoning concern, research on the prevalence, etiological factors and presentation patterns is limited in LAMI countries, leading to a minimal understanding of the disorder at individual, professional and societal level. There is an urgent need to enhance awareness and education to decrease stigma that maybe associated with autism. Partnering with entities like Autism Speaks is a potential step forward as they partner with local stakeholders to develop a culturally appropriate campaign focusing on the need for early diagnosis and intervention. For a country with very limited local resources, a collaborative approach with international partner...
In Pakistan, the treatment gap for mental disorders is significantly high. Pakistan faces a uniqu... more In Pakistan, the treatment gap for mental disorders is significantly high. Pakistan faces a unique problem of sustainable delivery. In 2009, WHO launched a mental health gap action program (mhGap) to provide evidence-based services at the primary and secondary level for the prevention and management of psychiatric and neurological disorders. This article highlights the discrepancies of the systems and issues related to mental health services provision in Pakistan. By discussing two initiatives of mhGap implementation for the Pakistani health system, authors have surveyed core areas where the sustainability of such a model can be compromised. The structural challenges marked by the stresses of an economy under pressure, poverty, health disparities, weak administration, allocation of resources and stigma attached to MNS exacerbated by both natural disasters and geopolitical crises make implementation an ongoing challenge. Despite these challenges, in recent years, Pakistan has taken p...
Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm bi... more Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm birth (PTB). The emerging literature examining this relationship reports inconsistent findings. The purpose of this systematic review was to summarize the available evidence exploring whether total ACEs predict PTB. A total of 386 studies were returned from searches on PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Nine studies were selected for final analysis and synthesis based on reporting of total ACEs and preterm birth gestational weeks or standard definition of birth before 37 weeks’ gestational age. A systematic review rather than meta-analysis was selected to present the findings given the clinical and methodological (e.g., sample studied, measurement tools) heterogeneity of the retrieved studies and pregnancy outcomes measured. The nine studies report on birth outcomes for 6,087 women from a range of sociodemographic and ethnic backgrounds. Despite a wide range of study designs, measurement tools, and timings of ACEs exposure across studies, seven of the nine included studies showed significant relationships between ACEs and PTB. Systematic review of the literature suggests that total ACEs are associated with PTB and provides an overview on the known associations. However, to date only nine studies have assessed this link, and more studies are needed, to explore the associations between ACEs and PTB using appropriate and valid instruments and doing so among more diverse populations. Future research should also explore possible biological mechanisms (allostatic load), and moderating and mediating variables.
Scholarship of Teaching and Learning in the South, 2020
There is a significant shortage of qualified psychiatrists and related service providers in Pakis... more There is a significant shortage of qualified psychiatrists and related service providers in Pakistan; this occurs in the backdrop of burgeoning evidence of a high prevalence of mental health disorders in the country. At the Aga Khan University Medical College, Psychiatry has been taught to the undergraduates as a mandatory one-month clinical rotation since 1987. AKU is the only medical college with a formal psychiatry training at the undergraduate level. In 2017, a team of faculty members reassessed the curriculum, teaching methodology and learning outcomes of the psychiatry rotation. As a result, an outcome-based, blended curriculum was devised that integrated virtual and classroom-based learning with patient skills training. The new curriculum has now been in implementation for one year. At the end of the rotation, a questionnaire was administered to determine students’ experience of online learning. WEBLEI was adapted to measure students’ perceptions across four subscales. Data w...
Background: Physical inactivity is a key contributor to the global burden of disease and dispropo... more Background: Physical inactivity is a key contributor to the global burden of disease and disproportionately impacts the wellbeing of people experiencing mental illness. Increases in physical activity are associated with improvements in symptoms of mental illness and reduction in cardiometabolic risk. Reliable and valid clinical tools that assess physical activity would improve evaluation of intervention studies that aim to increase physical activity and reduce sedentary behaviour in people living with mental illness. Methods: The five-item Simple Physical Activity Questionnaire (SIMPAQ) was developed by a multidisciplinary, international working group as a clinical tool to assess physical activity and sedentary behaviour in people living with mental illness. Investigators from 43 centres in 23 countries collected reliability and validity data on the SIMPAQ from patients with DSM or ICD mental illness diagnoses. Test-retest repeatability was assessed one-week apart. Results: Criterio...
Journal of the American Academy of Child & Adolescent Psychiatry, 2016
Square. To assess psychiatric symptoms in these children, a specially designed questionnaire was ... more Square. To assess psychiatric symptoms in these children, a specially designed questionnaire was used to detect symptoms and impairments. Results: Children attending schools near Tahrir Square showed high rates of depression, PTSD, and symptoms of anxiety. Nearly 70 percent reported symptoms of PTSD, and 62 percent stated that they have depressed mood. The risk factors were as follows: a negative perception of the effect of the revolution, knowing someone exposed to trauma, female gender, and low socioeconomic class. There were very high percentages of PTSD symptoms reflecting the sustained feelings of insecurity and stress reactions that the children are experiencing. This finding is consistent with other studies in that emotional insecurity, an indicator of safety perception of the community, was more strongly associated with political violence (intergroup hostility) than community violence (interpersonal hostility). A number of factors may be relevant to this finding. First, the location of the schools was around the main conflict area (Tahrir Square), providing a continual reminder of the incident and recurrent trigger of trauma memories. Second, many children and families living in streets nearby were not directly exposed to the trauma; however, the dominance of recorded events could have easily exposed schoolchildren to those traumatic events. Finally, the group nature of the Egyptian political conflict may have contributed to higher rates of probable PTSD symptoms. Conclusions: Close and proper monitoring of children living in such environments is highly recommended. The results highlight the need for largescale studies to explore the consequences of ongoing political violence on children and the need for effective interventions that foster children's emotional security.
The authors examined clinical differences between divalproex sodium and generic immediate-release... more The authors examined clinical differences between divalproex sodium and generic immediate-release valproic acid. This 6-year prospective, quasi-experimental clinical trial compared the effectiveness and tolerability of divalproex and valproic acid. The dependent variables were length of hospital stay, rehospitalization rate, and adverse drug reactions in 9,260 psychiatric admissions. Inpatients who initially received divalproex sodium had a 32.7% longer hospital stay and 3.8% higher readmission rate than did patients who initially received valproic acid. Initial treatment with divalproex prolonged length of stay by 30.3% in patients treated with divalproex and valproic acid during different admissions. After other variables were controlled by multiway analysis of variance, the hospital stay of patients who continued the initial medication was 15.2% longer (2.0 days) for divalproex than valproic acid. Switching medications was more common for valproic acid, partly because of study de...
Objective: Child mental health promotion and implementation of research initiatives have been par... more Objective: Child mental health promotion and implementation of research initiatives have been particularly challenging in Low and Middle Income (LAMI) countries. Pakistan is one such country facing challenges in recognition, awareness and promotion of its pediatric mental health needs. Methods: A review of the literature was done to identify the epidemiology, challenges to recognition and delivery and resources available regarding pediatric mental health disorders. From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. The numerous challenges that developing countries like Pakistan face in the promotion and implementation of child mental health care are discussed and include stigma, illiteracy, lack of adequate statistical data and severe shortage of pediatric psychiatrists. Results: From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. Conclusion: Creative ways of implementing and incorporating child mental health services within the existing systems of care are needed in LAMI countries like Pakistan.
Background: Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are... more Background: Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are prevalent in children with SLE. There are few data on the evaluation and management of psychotic features in children with this systemic autoimmune disorder. Objective: The authors describe contemporary Child and Adolescent Psychiatry Consultation and Liaison service management of acute psychosis in children with lupus. Method: The authors reviewed the records (2003-2008) of all pediatric SLE inpatients who were administered a traditional or atypical antipsychotic agent. They describe clinical features, initial and discharge mental status examinations, and inpatient psychotropic medication usage. Results: Ten pediatric SLE patients (age 10-19 years) required psychiatric management for psychosis during the review period. Paranoid delusions (70%), visual hallucinations (60%), and auditory hallucinations (60%) were the most common psychotic symptoms documented. All children were initially treated with an antipsychotic medication. Seven children were maintained on an atypical antipsychotic during their hospitalization. Two children had extrapyramidal signs, but no other adverse events were documented. All children were improved at discharge, and 40% had complete resolution of psychosis; 8 of the 10 patients were discharged on a psychotropic medication. Discussion: Psychotic manifestations associated with severe disease presentations were successfully treated by child psychiatrists. Atypical antipsychotics were well-tolerated and used as an adjunct to immunosuppressive regimens in these patients. Prospective studies are necessary to improve the care of children and adolescents with SLE and severe psychiatric manifestations.
Journal of the American Academy of Child & Adolescent Psychiatry, 2013
This article may be revised during the JAACAP copyediting, author query, and proof reading proces... more This article may be revised during the JAACAP copyediting, author query, and proof reading processes. Any final changes in the document will be made at the time of print publication and will be reflected in the final electronic version of the Practice Parameter. AACAP and JAACAP, and its respective employees, are not responsible or liable for the use of any such inaccurate or misleading data, opinion, or information contained in this iteration of this Practice Parameter.
Neurologic and psychiatric manifestations are prevalent in children and adults with lupus (labele... more Neurologic and psychiatric manifestations are prevalent in children and adults with lupus (labeled by convention neuropsychiatric systemic lupus erythematosus or NPSLE). However, there is a paucity of data on the evaluation and management of NPSLE in youth, with only a few publications describing the use of atypical antipsychotics in children and adolescents with lupus. In children, aripiprazole, a D2/5-HT1A partial agonist, appears to cause less prominent metabolic derangements than other second-generation antipsychotics. This agent may be an important tool in the treatment of pediatric patients with lupus who are at risk for weight gain and dyslipidemia due to disease and corticosteroid effects. The authors present two cases in which psychiatric symptoms associated with treatment-refractory lupus responded to aripiprazole pharmacotherapy.
Child and Adolescent Psychiatric Clinics of North America, 2010
Cultural competence is the ability of health care professionals to communicate with and effective... more Cultural competence is the ability of health care professionals to communicate with and effectively provide high-quality care to patients from diverse sociocultural backgrounds. Aspects of diversity include-but go beyond-race, ethnicity, gender, sexual orientation, religion, and country of origin. 1 In response to the increasing diversity of many industrialized societies, educational efforts have been aimed at educating medical trainees to address the needs of a heterogeneous patient population. It is imperative that the child and adolescent psychiatric community prepare for the changing world to provide appropriate, accessible, and quality clinical care. The first step toward this goal is to understand the role of culture and cultural competence in clinical care. As the field of cultural competence has evolved, the goal has moved from educating clinicians in the categorical approach-that of becoming skilled at knowledge, attitudes, and practices of a particular cultural group of patients-to a focus on the development of a set of skills and framework. This culturally competent therapeutic stance is an orientation that places medicine and patients in a social, cultural, and historical context. The overall aim is the open acknowledgment of the dignity and autonomy of, and delivery of high-quality medical care to all members of society, regardless of gender, race, ethnicity, religion, sexual orientation, language, geographic origin, or socioeconomic background. 2
face-to-face (F2F) recruitment programme in 2018 with our first remote recruitment programme in 2... more face-to-face (F2F) recruitment programme in 2018 with our first remote recruitment programme in 2020. In a world of fast paced technology, we reflect on what lies in the horizon for international psychiatric recruitment. Method. The recruitment programme was organised by 4 psychiatric trainees affiliated to each mental health trust. A two-day remote programme on the Zoom platform comprising of 45-minute slots was created. Through their own experiences of inspirational speakers, trainees contacted speakers representing different specialities, teaching styles and philosophical outlooks. Pre and Post Programme questionnaires and certificates of attendance were shared with speakers and attendees. These were compared with Pre and Post Programme questionnaires from the F2F event in 2018. Result. When compared to the 2018 F2F programme, the 2020 virtual recruitment programme attracted a higher number and wider variety of applicants, in gender (62% female/38%male), nationality (UK 79%/Non-UK 22%), as well as wider distribution in age, UK deanery and training position. Despite the elimination of cost, the quality of teaching was rated higher than F2F due to the availability of high quality speakers (100% would recommend to a friend; 72% rated excellent). Whilst the programme was effective in changing minds, this did not exceed F2F recruitment rates. F2F recruitment feedback focussed on inclusion of subspecialities, whereas virtual programme feedback focussed on ways to enhance interaction. Feedback focussed on technological applications such as interactive quizzes, breakout rooms, play-acting, and having the benefit of clinical vignettes or speakers' personal stories to bring talks to life. Conclusion. The use of remote technology transcended geographical and demographic frontiers. A variety of high-quality speakers, directly appealing to an international cohort were sourced, at no monetary cost. In future, the budget will be used in interactive applications, and time-limited session recordings. As the participants hungered for personal connections, we recommend a blended programme, with links to taster sessions, retaining the advantages of both strategies.
Islamophobia is a fear of or prejudice towards Muslims which can affect both the adult and pediat... more Islamophobia is a fear of or prejudice towards Muslims which can affect both the adult and pediatric population. Exposure to racial discrimination or other forms of overt or covert prejudice during the stages of racial identity formation could lead to the development of Islamophobia in children and adolescents. Historical and current events in which Muslims are portrayed in a negative way in the media may also play an important role in the etiology of Islamophobia in this population. Exposure to Islamophobic elements may affect the process of identity formation in Muslim children and adolescents, leading to poor self-esteem and possibly mental health conditions later in life. Muslim children and adolescents are also at a greater risk of being victims of bullying and acts of aggression. These individuals may also develop impaired relationship with parents, peers, and society in general. Parents and clinicians have a significant role in helping these individuals. It is important to ha...
Background Screening for changes in pregnancy-related anxiety and depressive symptoms during preg... more Background Screening for changes in pregnancy-related anxiety and depressive symptoms during pregnancy may further our understanding of the relationship between these two variables and preterm birth. Objectives To determine whether changes in pregnancy-related anxiety and depressive symptoms during pregnancy influence the risk of preterm birth among Pakistani women; explore whether perceived stress moderates or mediates this relationship, and examine the relationship between the various components of pregnancy-related anxiety and preterm birth. Methods A prospective cohort study design was used to recruit a diverse sample of 300 low-risk pregnant women from four centers of Aga Khan Hospital for Women and Children in Karachi, Pakistan. Changes in pregnancy-related anxiety and depressive symptoms during pregnancy were tested. Multiple logistic regression analysis was used to determine a predictive model for preterm birth. We then determined if the influence of perceived stress could m...
Autism is a pervasive, neurodevelopmental disorder characterized by stereotyped movements and imp... more Autism is a pervasive, neurodevelopmental disorder characterized by stereotyped movements and impairment in social skills and communication patterns. Prevalence patterns show an increasing burden of about 1 in 150 children affected by the disorder. Most affected individuals have symptoms that interfere greatly with quality of life. Although a burgeoning concern, research on the prevalence, etiological factors and presentation patterns is limited in LAMI countries, leading to a minimal understanding of the disorder at individual, professional and societal level. There is an urgent need to enhance awareness and education to decrease stigma that maybe associated with autism. Partnering with entities like Autism Speaks is a potential step forward as they partner with local stakeholders to develop a culturally appropriate campaign focusing on the need for early diagnosis and intervention. For a country with very limited local resources, a collaborative approach with international partner...
In Pakistan, the treatment gap for mental disorders is significantly high. Pakistan faces a uniqu... more In Pakistan, the treatment gap for mental disorders is significantly high. Pakistan faces a unique problem of sustainable delivery. In 2009, WHO launched a mental health gap action program (mhGap) to provide evidence-based services at the primary and secondary level for the prevention and management of psychiatric and neurological disorders. This article highlights the discrepancies of the systems and issues related to mental health services provision in Pakistan. By discussing two initiatives of mhGap implementation for the Pakistani health system, authors have surveyed core areas where the sustainability of such a model can be compromised. The structural challenges marked by the stresses of an economy under pressure, poverty, health disparities, weak administration, allocation of resources and stigma attached to MNS exacerbated by both natural disasters and geopolitical crises make implementation an ongoing challenge. Despite these challenges, in recent years, Pakistan has taken p...
Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm bi... more Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm birth (PTB). The emerging literature examining this relationship reports inconsistent findings. The purpose of this systematic review was to summarize the available evidence exploring whether total ACEs predict PTB. A total of 386 studies were returned from searches on PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Nine studies were selected for final analysis and synthesis based on reporting of total ACEs and preterm birth gestational weeks or standard definition of birth before 37 weeks’ gestational age. A systematic review rather than meta-analysis was selected to present the findings given the clinical and methodological (e.g., sample studied, measurement tools) heterogeneity of the retrieved studies and pregnancy outcomes measured. The nine studies report on birth outcomes for 6,087 women from a range of sociodemographic and ethnic backgrounds. Despite a wide range of study designs, measurement tools, and timings of ACEs exposure across studies, seven of the nine included studies showed significant relationships between ACEs and PTB. Systematic review of the literature suggests that total ACEs are associated with PTB and provides an overview on the known associations. However, to date only nine studies have assessed this link, and more studies are needed, to explore the associations between ACEs and PTB using appropriate and valid instruments and doing so among more diverse populations. Future research should also explore possible biological mechanisms (allostatic load), and moderating and mediating variables.
Scholarship of Teaching and Learning in the South, 2020
There is a significant shortage of qualified psychiatrists and related service providers in Pakis... more There is a significant shortage of qualified psychiatrists and related service providers in Pakistan; this occurs in the backdrop of burgeoning evidence of a high prevalence of mental health disorders in the country. At the Aga Khan University Medical College, Psychiatry has been taught to the undergraduates as a mandatory one-month clinical rotation since 1987. AKU is the only medical college with a formal psychiatry training at the undergraduate level. In 2017, a team of faculty members reassessed the curriculum, teaching methodology and learning outcomes of the psychiatry rotation. As a result, an outcome-based, blended curriculum was devised that integrated virtual and classroom-based learning with patient skills training. The new curriculum has now been in implementation for one year. At the end of the rotation, a questionnaire was administered to determine students’ experience of online learning. WEBLEI was adapted to measure students’ perceptions across four subscales. Data w...
Background: Physical inactivity is a key contributor to the global burden of disease and dispropo... more Background: Physical inactivity is a key contributor to the global burden of disease and disproportionately impacts the wellbeing of people experiencing mental illness. Increases in physical activity are associated with improvements in symptoms of mental illness and reduction in cardiometabolic risk. Reliable and valid clinical tools that assess physical activity would improve evaluation of intervention studies that aim to increase physical activity and reduce sedentary behaviour in people living with mental illness. Methods: The five-item Simple Physical Activity Questionnaire (SIMPAQ) was developed by a multidisciplinary, international working group as a clinical tool to assess physical activity and sedentary behaviour in people living with mental illness. Investigators from 43 centres in 23 countries collected reliability and validity data on the SIMPAQ from patients with DSM or ICD mental illness diagnoses. Test-retest repeatability was assessed one-week apart. Results: Criterio...
Journal of the American Academy of Child & Adolescent Psychiatry, 2016
Square. To assess psychiatric symptoms in these children, a specially designed questionnaire was ... more Square. To assess psychiatric symptoms in these children, a specially designed questionnaire was used to detect symptoms and impairments. Results: Children attending schools near Tahrir Square showed high rates of depression, PTSD, and symptoms of anxiety. Nearly 70 percent reported symptoms of PTSD, and 62 percent stated that they have depressed mood. The risk factors were as follows: a negative perception of the effect of the revolution, knowing someone exposed to trauma, female gender, and low socioeconomic class. There were very high percentages of PTSD symptoms reflecting the sustained feelings of insecurity and stress reactions that the children are experiencing. This finding is consistent with other studies in that emotional insecurity, an indicator of safety perception of the community, was more strongly associated with political violence (intergroup hostility) than community violence (interpersonal hostility). A number of factors may be relevant to this finding. First, the location of the schools was around the main conflict area (Tahrir Square), providing a continual reminder of the incident and recurrent trigger of trauma memories. Second, many children and families living in streets nearby were not directly exposed to the trauma; however, the dominance of recorded events could have easily exposed schoolchildren to those traumatic events. Finally, the group nature of the Egyptian political conflict may have contributed to higher rates of probable PTSD symptoms. Conclusions: Close and proper monitoring of children living in such environments is highly recommended. The results highlight the need for largescale studies to explore the consequences of ongoing political violence on children and the need for effective interventions that foster children's emotional security.
The authors examined clinical differences between divalproex sodium and generic immediate-release... more The authors examined clinical differences between divalproex sodium and generic immediate-release valproic acid. This 6-year prospective, quasi-experimental clinical trial compared the effectiveness and tolerability of divalproex and valproic acid. The dependent variables were length of hospital stay, rehospitalization rate, and adverse drug reactions in 9,260 psychiatric admissions. Inpatients who initially received divalproex sodium had a 32.7% longer hospital stay and 3.8% higher readmission rate than did patients who initially received valproic acid. Initial treatment with divalproex prolonged length of stay by 30.3% in patients treated with divalproex and valproic acid during different admissions. After other variables were controlled by multiway analysis of variance, the hospital stay of patients who continued the initial medication was 15.2% longer (2.0 days) for divalproex than valproic acid. Switching medications was more common for valproic acid, partly because of study de...
Objective: Child mental health promotion and implementation of research initiatives have been par... more Objective: Child mental health promotion and implementation of research initiatives have been particularly challenging in Low and Middle Income (LAMI) countries. Pakistan is one such country facing challenges in recognition, awareness and promotion of its pediatric mental health needs. Methods: A review of the literature was done to identify the epidemiology, challenges to recognition and delivery and resources available regarding pediatric mental health disorders. From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. The numerous challenges that developing countries like Pakistan face in the promotion and implementation of child mental health care are discussed and include stigma, illiteracy, lack of adequate statistical data and severe shortage of pediatric psychiatrists. Results: From a few studies that have been done, the mean prevalence of pediatric mental health disorders was found to be15.8%. Behavioral symptoms were found to be the most common cause of referral and ADHD the most common diagnosis. Conclusion: Creative ways of implementing and incorporating child mental health services within the existing systems of care are needed in LAMI countries like Pakistan.
Background: Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are... more Background: Neurological and psychiatric manifestations of systemic lupus erythematosus (SLE) are prevalent in children with SLE. There are few data on the evaluation and management of psychotic features in children with this systemic autoimmune disorder. Objective: The authors describe contemporary Child and Adolescent Psychiatry Consultation and Liaison service management of acute psychosis in children with lupus. Method: The authors reviewed the records (2003-2008) of all pediatric SLE inpatients who were administered a traditional or atypical antipsychotic agent. They describe clinical features, initial and discharge mental status examinations, and inpatient psychotropic medication usage. Results: Ten pediatric SLE patients (age 10-19 years) required psychiatric management for psychosis during the review period. Paranoid delusions (70%), visual hallucinations (60%), and auditory hallucinations (60%) were the most common psychotic symptoms documented. All children were initially treated with an antipsychotic medication. Seven children were maintained on an atypical antipsychotic during their hospitalization. Two children had extrapyramidal signs, but no other adverse events were documented. All children were improved at discharge, and 40% had complete resolution of psychosis; 8 of the 10 patients were discharged on a psychotropic medication. Discussion: Psychotic manifestations associated with severe disease presentations were successfully treated by child psychiatrists. Atypical antipsychotics were well-tolerated and used as an adjunct to immunosuppressive regimens in these patients. Prospective studies are necessary to improve the care of children and adolescents with SLE and severe psychiatric manifestations.
Journal of the American Academy of Child & Adolescent Psychiatry, 2013
This article may be revised during the JAACAP copyediting, author query, and proof reading proces... more This article may be revised during the JAACAP copyediting, author query, and proof reading processes. Any final changes in the document will be made at the time of print publication and will be reflected in the final electronic version of the Practice Parameter. AACAP and JAACAP, and its respective employees, are not responsible or liable for the use of any such inaccurate or misleading data, opinion, or information contained in this iteration of this Practice Parameter.
Neurologic and psychiatric manifestations are prevalent in children and adults with lupus (labele... more Neurologic and psychiatric manifestations are prevalent in children and adults with lupus (labeled by convention neuropsychiatric systemic lupus erythematosus or NPSLE). However, there is a paucity of data on the evaluation and management of NPSLE in youth, with only a few publications describing the use of atypical antipsychotics in children and adolescents with lupus. In children, aripiprazole, a D2/5-HT1A partial agonist, appears to cause less prominent metabolic derangements than other second-generation antipsychotics. This agent may be an important tool in the treatment of pediatric patients with lupus who are at risk for weight gain and dyslipidemia due to disease and corticosteroid effects. The authors present two cases in which psychiatric symptoms associated with treatment-refractory lupus responded to aripiprazole pharmacotherapy.
Child and Adolescent Psychiatric Clinics of North America, 2010
Cultural competence is the ability of health care professionals to communicate with and effective... more Cultural competence is the ability of health care professionals to communicate with and effectively provide high-quality care to patients from diverse sociocultural backgrounds. Aspects of diversity include-but go beyond-race, ethnicity, gender, sexual orientation, religion, and country of origin. 1 In response to the increasing diversity of many industrialized societies, educational efforts have been aimed at educating medical trainees to address the needs of a heterogeneous patient population. It is imperative that the child and adolescent psychiatric community prepare for the changing world to provide appropriate, accessible, and quality clinical care. The first step toward this goal is to understand the role of culture and cultural competence in clinical care. As the field of cultural competence has evolved, the goal has moved from educating clinicians in the categorical approach-that of becoming skilled at knowledge, attitudes, and practices of a particular cultural group of patients-to a focus on the development of a set of skills and framework. This culturally competent therapeutic stance is an orientation that places medicine and patients in a social, cultural, and historical context. The overall aim is the open acknowledgment of the dignity and autonomy of, and delivery of high-quality medical care to all members of society, regardless of gender, race, ethnicity, religion, sexual orientation, language, geographic origin, or socioeconomic background. 2
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