Specialty training in child and adolescent psychiatry in India

Referral Patterns, Pathways to Care, Symptom Profile, and Diagnoses of Children Attending a Child Psychiatry Unit in South India: A Retrospective Chart Review

Background

Childhood mental disorders are a major global concern, particularly in India. Despite efforts to establish child psychiatry services, the treatment gap persists. This study investigates referral patterns, pathways to care, and diagnostic trends among children attending a child psychiatry unit (CPU).

Methods

A retrospective chart review (2017-2022) was conducted at the CPU of Kasturba Medical College, Manipal. Two investigators analyzed 1,046 files, extracting data on demographics, pathways to care, reasons for referral, and diagnoses. Inter-rater reliability was confirmed, and associations between pathways to care, diagnosis, and demographics were examined.

Results

This study included children with a mean age of 11.2 years, predominantly male (63.2%). Most children (97.5%) first sought care from a healthcare provider, with 29.3% consulting mental health professionals (MHPs) and 59.6% visiting medical specialists. Primary reasons for referral included behavioral disturbances, emotional disturbances, and academic decline. Common primary diagnoses were attention deficit hyperactivity disorder (16.5%), mental retardation (14.7%), and pervasive developmental disorder (12.6%). Significant associations were found between pathways to care and diagnosis (P = .001), as well as between gender and both referral reasons (P < .001) and diagnoses (P < .001).

Conclusions

The study provides insights into the demographic and clinical characteristics of children with mental health problems in India. The medical model of care pathways is a positive shift, and these findings can guide gender- and culture-sensitive service planning, optimize resource allocation, and inform future research in child psychiatry.

Inequalities in COVID-19 impact on preschool mental health in India: key moderators of adverse outcome

ABSTRACT

Introduction

Worldwide research suggests that the COVID-19 pandemic had little to no overall effect on preschool children's mental health, but that the impact is variable depending on pre-existing and COVID-19-related inequalities. Evidence from low- and middle-income country settings is sparse, yet effects may be more variable due to greater inequalities. We provide the first empirical evidence for the impact of the pandemic on emotional and behavioural problems in Indian preschool children, after accounting for normative age-related change, and test whether the impact varied depending on COVID-19-related inequalities.

Methods

Families participating in an Indian-based prospective longitudinal birth cohort (Bangalore Child Health and Development Study) provided data at age 2 years (before COVID-19) and again during COVID-19 (n=528). Mothers reported child emotional and behavioural problems and a range of COVID-19-related adverse experiences.

Results

There was a small overall pandemic effect on emotional (rate ratio (RR)=1.31, p=0.040), but not behavioural problems, after adjusting for age-related change. However, compared with the lowest risk level, emotional and behavioural problems rose higher compared with whole sample age-expected rates in families who reported the highest levels of perceived negative impact of COVID-19-related adversities (moderation p<0.001, RR=2.43 and p<0.001, RR=1.32), COVID-19 life events (p<0.001, RR=3.28, and p<0.001, RR=1.26) and time the child spent playing alone (p<0.001, RR=2.49). Emotional problems rose higher with high perceived COVID-19 maternal stress (p=0.013, RR=1.57) and with increased child mobile phone use (p<0.001, RR 1.48). Secondary analyses controlling for variation in age trends within moderator subgroups revealed these to be rarely significant. Where significant and accounted for, having more children living at home emerged as protective, whereas living below the poverty line emerged as a risk for adverse pandemic impact on child mental health.

Conclusion

A small overall increase in preschool mental health problems was evident. However, this masked substantial worsening of such problems in families with elevated COVID-19 adversities in India. These findings can inform the targeting of policy and practice initiatives to better mitigate adverse longer-term mental health outcomes arising from the pandemic response.

Advances in Psychiatry Training and Faculty Development in India

Background

This review examines the historical developments, current state of training, existing challenges, and opportunities for undergraduate, postgraduate, and super specialty psychiatry education in India.

Methods

For this narrative review, we examined information from the published literature, along with key documents from the Indian Psychiatric Society, the National Medical Commission, and other relevant sources.

Conclusions

In India, psychiatry training has seen significant advancements since independence, particularly in the past decade, driven by the recommendations of the Indian Psychiatric Society and the introduction of competency-based medical education by the National Medical Commission. This transformation has redefined undergraduate and postgraduate training across all medical disciplines, including psychiatry. The shift has moved away from traditional, time-bound frameworks toward a focus on acquiring specific competencies essential for effective clinical practice. This approach ensures that trainees gain theoretical knowledge and develop practical skills and professional attitudes crucial for patient care. However, a major challenge highlighted in this review is the transition of senior residents to faculty roles without adequate training in teaching, research, academia, and leadership. Despite this, they are expected to excel in these areas upon assuming faculty positions. To address this gap, we emphasize the urgent need for a comprehensive faculty development program for early career faculty. Our proposed initiative aims to bridge these gaps and support the development of future leaders and educators in psychiatry. The recommendations outlined in this review seek to create a robust educational environment that will cultivate the next generation of psychiatrists in India.

Adequate Management of Autism Spectrum Disorder in Children in India

Despite the significant burden of neurodevelopmental disorders such as autism spectrum disorder (ASD) in India, there are areas of unmet needs at every level of the health care system. This includes screening and recognition, reliable and valid tools to evaluate, and to adequately manage ASD. There are also gaps in education and training of medical professionals, paraprofessionals, special education teachers and the related services. Lack of public awareness and cultural factors contribute to delays in early recognition and interventions. A framework is suggested to address these unmet needs at various levels to improve the care of these children with ASD. These include a) a focus on education of medical professionals, paraprofessionals, and teachers; b) setting up infrastructure at community, regional, and statewide levels, with adequate funding; and c) use of audiovisual technology and collaboration with international expertise.

Competency-based child and adolescent psychiatry curriculum for Indian medical graduates: Need of the hour

The National Medical Council of India has introduced a Competency-Based Medical Curriculum for structured training of Indian Medical Graduates. The curriculum envisages training of the medical graduate in Bloom's cognitive, affective and communication skills as per Miller's competence framework. This competency-based curriculum has opened the way towards a structured training program for medical graduates to impart evidence-based teaching and groom them into holistic physicians. The introduction of psychiatry early into the medical graduate curriculum is a welcome step that can generate interest towards the specialty and provide core knowledge and clinical psychiatric skills. In this background, the author proposes introducing a structured Child and Adolescent psychiatry curriculum for undergraduates, which can prepare future doctors to provide child and adolescent psychiatric care in routine clinical settings. This competency-based child and adolescent psychiatry curriculum would help inculcate developmentally and socially appropriate knowledge, attitude and communication skills in managing child and adolescent psychiatric disorders.

[Training of higher qualification Specialists in children and adolescent psychiatry in Russia and other countries]

Most mental disorders occur before the age of 25 years, and if left without intervention, they can transform into more severe mental disorders. Despite the great need to protect the mental health of children and adolescents, in Russia and most countries of the world, there is a shortage of qualified personnel in this area. The article presents data on the availability of personnel in different countries of the world, including Russia. The issues of organizing the training of child and adolescent psychiatrists in Russia and various countries are examined, and the available data on training programs are analyzed. Educational opportunities for child and adolescent psychiatry in Russia are examined in detail.

Referral Trends in Two Pioneering Developmental-Behavioral Pediatric Centers in Turkey

OBJECTIVE

To inform professionals pioneering developmental-behavioral pediatrics (DBP) services in low- and middle-income countries (LMICs), we aimed to examine referral trends in 2 pioneering DBP centers at different locations in Turkey and to ascertain whether the official establishment of DBP as a subspecialty affected these trends.

METHOD

This longitudinal observational study included all children referred to Ankara (AUDPD) and Inonu (IUDPD) Universities' Developmental Pediatrics Divisions between 2010 and 2018. We examined the sources of referrals and the independent effects of time and the establishment of DBP as a subspecialty on referral volume using Negative Binomial Regression (NBR) models.

RESULTS

Of 8,051 children, most were boys (58%) and under 24 months of age (72%). Most referrals were from the pediatric and pediatric surgery department clinics (85%); less than 1% were from child and adolescent psychiatry, and none were from family physicians. The NBR models showed that yearly, the referral volume increased significantly, 1.18-fold (95% confidence interval [CI] = 1.09-1.28) and 1.48-fold (95% CI = 1.20-1.82) for AUDPD and IUDPD, respectively. Compared with the trend of referrals before, the trend after the establishment of DBP as a subspecialty increased significantly at AUDPD, but not IUDPD.

CONCLUSION

The increase in referrals to DBP over time is encouraging to professionals working to advance DBP services and training in LMICs even if DBP is not officially established as a subspecialty. Additional efforts may be needed to improve recognition and use of DBP services by community physicians and allied disciplines that provide services to children.

The state of psychiatric research in the Asia Pacific region

INTRODUCTION

This study aims to review recent scientific publications and research output in the field of psychiatry, from a series of countries in the Asia-Pacific region (Australia, India, Indonesia, Iran, Lebanon, Malaysia, and Nepal), with a view to identify themes and similarities across regions, as well as to examine the barriers and challenges in mental health research faced by countries in the region.

METHODS

Seven psychiatrists from seven countries reviewed recent published and ongoing research in psychiatry in their respective nations, with respect to themes, as well as any barriers or challenges faced by mental health researchers.

RESULTS

While the seven nations included in this review vary in terms of research capabilities and economic development level, they share many similarities both in terms of research direction, and with regards to challenges faced. Limitations in the form of sociocultural differences from the West, and a lack of funding were some of the barriers identified.

DISCUSSION

Mental health research in the region has been progressing well. However, more varied research in the form of qualitative or economic studies are lacking, as are multi-center studies. The similar issues that nations face with regards to research could perhaps benefit from collaborative efforts and initiatives for the furtherance of research in the region.

Depression among adolescents in a rural community of north India: A cross-sectional study

Background:

There is a paucity of literature on depression among adolescents in the north Indian community.

Objectives:

The aim of this study was to estimate the prevalence of depression among adolescents residing in a rural community of north India, and to determine associated factors, psychiatric comorbidities, and functional impairment.

Methods:

A simple random sample of 630 adolescents aged 10-19 years was drawn. Participants were enrolled in house-to-house visits, and screened for depression using the nine-item version of Patient Health Questionnaire (PHQ-9). Diagnostic confirmation and assessment of psychiatric comorbidities was done using Mini International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) for 10-17-year-old adolescents, and MINI for 18 year olds. Prevalence was reported with 95% confidence interval. Multivariable logistic regression analysis was done to determine the association of depression with socio-demographic and other factors. Children's Global Assessment Scale (CGAS) was used to assess functional impairment.

Results:

The prevalence of depression was 3.7% (95% CI: 2.3–5.2) (n = 583), comparable in both sexes. Over half the participants with depression had psychiatric comorbidities; the most common were conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder; nearly two-fifth had suicidal ideas/attempt. About two-third of participants with depression had functional impairment. Depression was associated with perceived frequent conflicts at home [adjusted odds ratio (aOR) = 4.0 (95% CI: 1.0-16.0), P = 0.049], and perceived stressful event (s) in past six months [aOR = 7.0 (95% CI: 2.4-20.3), P < 0.01], which were predominantly related to academics.

Conclusion:

Study results indicate the need to strengthen diagnostic and therapeutic/rehabilitative mental health services in adolescent age group. Low-stress lifestyle could be a promising approach to sidestep depressive symptoms.

Child and adolescent psychiatry training in Nepal: early career psychiatrists' perspective

BACKGROUND

Nepal is a developing low-income country in Southeast Asia. There is a huge burden of child and adolescent mental health (CAMH) in Nepal which has a population of around 29 million and 40-50% of the population comprises of children and adolescents. Child and Adolescent Psychiatry (CAP) has not been formally recognized as a subspecialty in Nepal and there is no standardized curriculum for CAP training. The objectives of the survey were to identify the current status of training, shortfalls and to explore the training experiences of early career psychiatrists (ECPs) in Nepal.

METHODS

The participants were ECPs in Nepal. An online questionnaire was created consisting of 20 questions including 3 questions requiring an answer indicating a level of agreement scored on a ten-point scale. Questionnaire using google form was e-mailed with the uniform resource locator (URL). Respondents anonymously answered the questions. The survey was open from 01/01/2019 to 01/04/2019.

RESULTS

Response rate was 83.69%. Around 42% (n = 32) were trainees in Doctor of Medicine (MD) Psychiatry and 58% (n = 45) of respondents had completed their MD Psychiatry. More than half of the ECPs had not received formal training specific to CAP. Seventy percent (n = 54) ECPs reported that their current workplace did not have a specific unit to address psychological problems in children and adolescents. However, 62% (n = 48) of ECPs came across 10 CAP cases per week. On a ten-point scale, mean score of ECPs confidence in diagnosing, management and overall confidence in CAP cases were 5.18 ± 1.56, 4.58 ± 1.59 and 4.67 ± 1.62 respectively. Fifty-four percent (n = 42) of respondents rated their training as limited and 74% (n = 57) of them wanted additional training in CAP. Psychological intervention, psychotherapy and a fellowship course were the additional training most of the ECPs wanted to receive.

CONCLUSION

Despite significant exposure to CAP patients in daily practice, ECPs self-evaluated their training as inadequate and there is no standardized CAP training program in Nepal for ECPs. The desire of ECPs to receive additional training in CAP is highly encouraging and positive. We advocate for the development and incorporation of CAP training in current psychiatry training to fulfill these unmet training needs in Nepal.