ANTON et al. ORIGINAL PAPERS CHARACTERISTICS OF NEURODEVELOPMENTAL DISORDERS IN THE CLINICAL POPULATION OF A MENTAL HEALTH CENTER Miruna RĂDAN 1, Mihaela GĂIȘTEANU 1 1 Alessandrescu-Rusescu National Institute for Maternal and Child Health, Bucharest, Romania ABSTRACT Neurodevelopmental disorders (ND) are characterized by deficits that produce impairments of personal, social, academic or occupational functioning which appear early in life and usually persist into adulthood. At present, there is limited knowledge on the prevalence of children s mental disorders in Romania. This paper presents a study that aims to provide a perspective on the occurrence rates and characteristics of mental disorders in the clinical population of the Children s Mental Health Center (CMH) of the Alessandrescu- Rusescu National Institute for Maternal and Child Health (NIMCH) during 2004-2007 and 2013-2015, with a special focus on neurodevelopmental disorders. The subjects were assigned to three groups: the autism spectrum disorder (ASD) group, the neurodevelopmental (ND) group and the learning disorders group (LD). The study targeted: 1) Occurrence rates of the disorders, 2) Comorbidity, 3) Risk factors - medical and psychosocial adversities, 4) Group characteristics - age, sex, intelligence, 5) Psychosocial support (family and school). The results show a high and raising occurrence of ND among children admitted at the CMH. Children with learning disorders represent a growing group, associated with maximum risk factors. The outcomes of the study provide an outline of the ND disorders profiles for the MHC children that may be used to design future research, to develop specific interventions and to improve medical services. Keywords: Neurodevelopmental disorder, autism spectrum disorder, learning disorder, comorbidity, services. Corresponding author: Miruna Rădan, PhD, Alessandrescu-Rusescu National Institute for Maternal and Child Health, Bucharest, CMH Center, Calea Griviței 71, 010705, Bucharest, Romania Phone, Fax: +40 021 316 9219. E-mail address: radan.miruna@iomc.ro Volume 4, Issues 3-4, July-December, 2016 15
RĂDAN et al. INTRODUCTION Autism is a neurodevelopmental disorder which affects an increasing number of children. According to the World Health Organization, mental health may be defined as a state of wellbeing in which the individual fulfills his or her own potential by achieving the skills for coping with and leading a productive life [3, 4]. For children, this condition involves the attainment of expected cognitive, emotional and social development milestones that make them able to function well at home, in school and in the community [5, 6]. 10-20% children worldwide suffer from mental disorders [7]. The impact is significant at the individual, family and community level, causing distress, increased risks and economic burden [2]. Mental disorders are one of the leading causes of disability [8]. Starting in childhood, they affect the whole life span of many people [8]. National epidemiological data on children s psychiatric morbidity in Romania is limited. A recent report of the Ministry of Health, based on public health services data, shows that children s mental disorders are underdiagnosed, as compared to international values [9]. Between 1% and 5% of the total children s population is diagnosed and receives basic mental health services [9]. The health authority report provides data for eight categories of mental disorders, but not for neurodevelopmental disorders (ND) - intellectual disabilities, communication disorders, specific learning disorders and motor disorders - that affect many children in our country. At present, there are 29 Centers for Children s Mental Health in Romania [9]. The services they offer are not sufficient to meet the needs of the population [9] and vary both in quantity and quality. Standardized best practices and a system for monitoring the outcomes of therapy have not yet been implemented. OBJECTIVE This paper presents a retrospective observational study aiming to provide a perspective on the occurrence rates and characteristics of mental disorders in the clinical population seeking treatment at the Children s Mental Health Center (CMH) of the National Institute for Maternal and Child Health (NIMCH). Our study has a focus on the group of ND disorders affecting the majority of the children referred to our outpatient services. The study targeted the following aspects: 1) Occurrence rates of the disorders; 2) Comorbidity; 3) Risk factors - medical and psychosocial adversities; 4) Group characteristics - age, sex, intelligence; 5) Psychosocial support (family and school). MATERIALS AND METHODS Participants Children included in the study were admitted in the CMH NIMCH during two periods of time, 2004-2007 and 2013-2015. The study included the following groups of subjects: 1) Autistic spectrum disorders group (ASD), N=112 children; 2) Neurodevelopmental disorders groups (ND) G1, N1=147 and G2, N2=118 subjects; 3) Learning disorders (LD) group N=40. The ASD, ND and LD groups in the study represent the total number of cases for each disorder out of all the new cases registered in one year. Children have been selected from the total number of new cases registered in one year at the CMH according to psychiatric diagnosis criteria for each category. Procedure We used data collected from the children s CMH medical records. The records include the professional assessments conducted by a children s psychiatrist, a clinical psychologist, a medical rehabilitation doctor and a speech therapist, with recommendations for treatment/intervention and 16 Romanian Journal of Child and Adolescent Psychiatry
Characteristics of neurodevelopmental disorders in the clinical population of a mental health center periodical follow-ups. Information about early development, personal medical history of the child and family, results of recommended additional medical investigations, such as EEG and MRI were also recorded. Children s specialized evaluations involved neurological testing, clinical medical examinations, parent interviews, standardized psychological tests and speech and language testing. The instruments used for the psychological assessment were standardized scales and tests: the Wechsler Scales of Intelligence for Children WISC- IV, (2003), the Stanford-Binet Scales of Intelligence (1986, Fourth Edition), the Merrill-Palmer Scales of Development (1948, 2004), the Autism Diagnostic Observation Schedule (ADOS, 2001), The Childhood Autism Rating Scale CARS (1992, Fourth Edition), and various behavioral scales and inventories. Psychiatric diagnoses were made based on the International Classification of Diseases ICD 10 [10], and the Diagnostic and Statistics Manual of Mental Disorders Fifth Edition [1]. Microsoft Office and Excel 2007 were used to organize, analyze and present the data. RESULTS Autism spectrum disorders (ASD) rates and associated problems The ASD occurrence rate in the CMH compared to the number of new cases in a year over four 12 month periods shows a constant and substantial increase between 2004 and 2007. Figure 2 ASD associated problems 112 children were diagnosed with ASD in the first 4 years of our study. Their group profile indicates high values of ASD associated problems. Almost half have an intellectual disability. ADHD/ODD is present in 27.7% of the cases, while 25.9% have three comorbid disorders, such as speech disorders, anxiety, tics, feeding disorders, sleep and elimination disorders. A group of children with multiple adversities including other medical and psycho-social problems was also identified, accounting for 24.1% of the ASD group. Figure 1 Autism spectrum disorders rates compared to the total number of new cases in a year Volume 4, Issues 3-4, July-December, 2016 17
RĂDAN et al. Neurodevelopmental disorder (ND) rates disabilities have the highest rates out of all disorders for both groups, increasing from 33.4% to 46.6% in the second year. ASD represent 23% of the new cases in 2013 and decrease to 13.5% in 2014, while the other categories of disorders show little variation; there is a small rise in the percentage of communication and language disorders, from 19.7% to 22.5%, and a small decrease in ADHD values, from 10.9% to 7.10%. Figure 3 - The main diagnostic categories compared to the total number of new cases in 2013 Figure 5 Neurodevelopmental disorders profile in 2013 Figure 4 - The main diagnostic categories rates compared to the total number of new cases in 2014 The percentages for ND disorders, compared to the other categories of disorders recorded over two 12 month periods, indicate that over 60% of the children receiving services belong to this category. According to the types of developmental Figure 6 Neurodevelopmental disorders profile in disorders, the profiles for the two groups identified in 2014 2013 and in 2014 are slightly different. Intellectual 18 Romanian Journal of Child and Adolescent Psychiatry
Characteristics of neurodevelopmental disorders in the clinical population of a mental health center Learning disorders (LD) Comprehensive assessments for diagnosing specific learning disorders were not available for most of our subjects, as in Romania standardized evaluation instruments for this category are lacking. The LD diagnosis is a category not often used in clinical practice. The LD group of this study included children who met most of the DSM 5 criteria for the disorder and experienced persistent academic difficulties. Figure 8 - Intelligence scores for the LD group The characteristics of the LD group (N = 40) show that boys account for 77.5% of subject, almost 50% of whom are referred to the centre after the age of 9, 35% after the age of 10, and only 30% between 6 and 7. 30% have low average IQ scores, 22.5% have borderline IQ scores and 15% have IQs of 60-70. 25% are in the high average range and only 7.5% have superior intelligence scores. Figure 7 - Learning disorders rates compared to the total number of new cases in a year Our data indicated lower rates than expected for the disorder, as compared with reported international prevalence [1], but values increased over the three years of the study, from 5.11% to 10.52%. Figure 9 - LD comorbid disorders 80% of the LD subjects have comorbid disorders. Anxiety disorders, ADHD, externalizing Volume 4, Issues 3-4, July-December, 2016 19
RĂDAN et al. disorders and other neurodevelopmental disorders are associated with LD. Over half of ADHD comorbid subjects have been identified with more than two comorbidities. 22.5% of the children have speech and language disorders. Attention difficulties are present in 27% of the children who do not have a clinical ADHD diagnosis. 5% of the LD children have supportive families to help them cope with their difficulties, while school support is available just for 2.5%. DISCUSSION The outcomes of the study show high occurrence rates for the neurodevelopmental disorders among children who address the CMH. In 2014 ND represent 67.8% of the new cases. The percentages of this group of disorders are increasing compared to other mental health problems for the time intervals 2004-2007 and 2013-2015. The intellectual disorders and of learning disorders rates within the group are growing, while ASD and ADHD rates have a decreasing trend. A small rise in percentage is observed for speech and language disorders. High comorbidity rates, with more than two disorders, are present in the LD, the ASD and the ADHD groups. We found that multiple medical and psychosocial adversities are associated to 24.1% of the ASD category. Children with LD have comorbid communication disorders and high rates of attention problems. Age, sex and IQ characteristics of the LD group, as well as the low availability of social support may signal additional risks that need further investigation. Although this study has statistical limitations, the results provide an outline of the ND disorder profiles for CMH children that may be used to design future research, to develop specific interventions and to improve services. Our findings point to the need of collecting community level data in order to establish standardized best practices and to plan for services. Increasing demands for services from various categories of children with complex associated problems such as those with neurodevelopmental disorders and high comorbidities call for specialized and better adapted interventions. Children in high risk categories should be make the focus of comprehensive assessment and treatment. Our data shows that children with learning disorders are an underdiagnosed, growing group, that meets maximum risk indicators. Their treatment requires standardized assessment techniques and multidisciplinary teams of professionals with adequate training. The present study highlights a group of disorders that affect a large number of children, offering information on the occurrence rates, comorbidities and possible risk signals for children registered with an outpatient clinic. Further research and national surveys should document efficient and flexible strategies for children s mental health services. Common efforts of practitioners, researchers and policy makers are needed in order to find better solutions for children with neurodevelpmental disorders in Romania. Acknowledgements This paper is based on a presentation given at the International Conference MENTAL HEALTH PSYCHOLOGY, MEDICINE AND ANTHROPOLOGY FOR LIFE QUALITY 2016, organized by The International Society for Applied Psychology, The Francisc Rainer Institute of Anthropology and The Natural Sciences Museum Ploiești, 9-11 September, Ploiești, Romania REFERENCES 1. American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders, Fifth 20 Romanian Journal of Child and Adolescent Psychiatry
Characteristics of neurodevelopmental disorders in the clinical population of a mental health center Edition. Arlington, VA, American Psychiatric Association. 2. Kieling C. et al. (2011), Child and adolescent mental health worldwide: evidence for action. The Lancet, 378, (9801): 1515 1525. DOI:http://dx.doi.org/10.1016/S0140-6736(11)60827-1. 3. Mental health policy and service guidance package: Child and adolescent mental health policies and plans, (2005), World Health Organization. Geneva, Switzerland. Available at: http://www.who.int/whr/2002/en/ 4. Waddell C. et al. (2013), Creating Comprehensive Children s Mental Health Indicators for British Columbia Canadian journal of community mental health, 32(1): 9-27. Published by Canadian Periodical for Community Studies Inc. DOI:10.7870/cjcmh-2013-003. 5. World Health Report 2002: Reducing Risks, Promoting Healthy Life, (2002), Geneva, Switzerland: WHO. Available at: http://www.who.int/whr/2002/en/ 6. Perou, R. et al. (2013), Mental Health Surveillance Among Children USA, 2005 2011, U.S. Department of Health and Human Services Centers for Disease Control and Prevention, MMWR, 62(2), Supplement: 1-35. Available at http://www.cdc.gov/mmwr/pdf/other/su6202.pdf 7. Child and adolescent mental health, World Health Organization. Available at: http://www.who.int/mental_health/maternalchild/child_adolescent/en/ 8. Merikangas, K.R. et al. (2009), Epidemiology of mental disorders in children - Dialogues in Clinical Neuroscience, 11(1): 7-20. 9. Guvernul României, Ministerul sănătăţii, Ministerul educaţiei naţionale și cercetării științifice, Ministerul muncii, familiei, protecţiei sociale, (2016) Strategia naţională pentru sănătatea mintală a copilului și adolescentului 2016-2020, București, 2016. Available at: http://www.ces.ro/newlib/pdf/proiecte/hg- Strategia-sanatate-mintala-copii-2016.pdf 10. ICD-10 Clasificarea tulburărilor mentale şi de comportament. Descrieri clinice şi îndreptare diagnostice (2016), coord. Mircea Lăzărescu, (transalation of The ICD-10 Classification of Mental and Behavioural Disorders. Clinical description and diagnostic guidelines, World Health Organization, 1992, 1993), editura Trei. AAAAA AAAAA AAAAA Volume 4, Issues 3-4, July-December, 2016 21
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