Overview of Intellectual Disability across the lifespan; Autism Spectrum Disorders; Service Development for Child and Adolescent Psychiatry; Legal Considerations in Child and Adolescent Psychiatry Mashudat Bello-Mojeed MBBS, MPH, MSc. CAMH, FCPA, FMCPsych, FWACP FNPH, Yaba, Lagos CCAMH, UI, Ibadan
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Overview of Intellectual Disability across the lifespan;
Autism Spectrum Disorders; Service Development for Child and
Adolescent Psychiatry; Legal Considerations in Child and
• Service Development for CAP: Sustainable and Principle of CAMH Services Development, System of Care frame work, Community CAMH Services Development
• Legal Consideration in CAP: Legal and Child Mental Health Legislation in Nigeria, Convention on the Right of the Child, Legal Considerations
Learning Outcomes : ID • At the end of the lecture, participants will be able
to:
• Understand the concept of intellectual disability (ID) across the life span
• Define, classify and conduct assessment for ID
• Identify the risk factor for and management of ID
•Intellectual Disability
Neurodevelopmental Disorders: ID and ASD
Concept of Neurodevelopmental Disorders: • Early onset
• CNS involvement
• Stable course
• Presents with behaviour problems
• Lifelong
• Disabling and disruptive to family
Intellectual Disability across the life span Introduction
• The use of stigmatising labels for individuals with disabilities such as ID (and ASD): idiots, imbecile, mentally deficient/defective, feeble minded
• Residential placement, custodial and abuse (Mid-1800)
• Advocacy and legislation for normalisation of living state and educational inclusion
• ID occurs across the life span but with variable outcome
• Evolution of terms:
• DSM-IV and ICD-10 = Mental Retardation
• DSM-V = Intellectual Disability
ID: Definitions & Terms
Definition of ID is based on three (3) Criteria:
• Significant limitations in intellectual functioning
• Significant limitations in adaptive functioning expressed in conceptual, social, and practical adaptive skills
• Age of Onset:
– Developmental period,
– before 18 years
ID: Definitions and Terms
• Adaptive functioning: refers to competency in independent and appropriate performance of daily activities/task within a cultural and age group
• Intellectual function: standardized instrument; IQ
• Adaptive behaviour could be viewed using a normal distribution/Gaussian curve
• Significant limitation: approximately 2 Standard Deviations (SD) below the mean of either 1 of the 3 adaptive behaviour: Conceptual, social and practical skills
Figure 1: IQ/Behaviour Distribution
Epidemiology
• Prevalence = 1 – 3 %
• Highest incidence in school age; peaks: 10-14yrs
• Lower rates in older adults
• Males>Females, 1.5:1
• Rates about twice in LMIC compared to HIC
Table1: ID Classifications and Characteristics Mild (IQ: 50-69) Moderate (IQ : 35-49) Severe (IQ: 20-34) Profound (IQ <20)
80% cases 12% cases 3-4% cases 1-2% cases
Communicate Communicate with some support
Limited vocabulary
No language
Learn basic self –help skill/household chores
learn basic skills with some support
May gain self-help skill through with intense support
Lack self-help skill
Academic (Educable): 6 years of formal education, transition issue
Academics: < 3 yrs formal education
Poor
Poor
Unskilled and semi-skilled work with som e support
Unskilled work with supervision (Trainable)
Assisted household chores (Trainable)
Totally dependent,
Brain abnormality in minority
Brain abnormality in majority
Sensory impairment (5-8 times)
Severe physical & neurological disorders
Causes usually unknown Prenatal causes in 30% (Mortality: 2x
Prenatal causes in 55 – 75%
Mortality: 7 -31x than general population
•Aetiology of ID:
a multifactorial construct
Table 2: Aetiology of ID Timing Biological Psychological/
• In 1944, Hans Asperger described a group of children termed to have traits of “autistic psychopath”
– Observed children with traits similar to that of Kanner's but with a relative sparing of language, cognition & age appropriate skills
– an important variant of classical autism referred to as “Asperger’s syndrome”
» high functioning autism
Classifications • ASD: A group of neurodevelopmental disorders
characterise by persistent and qualitative impairment in social communication, social interaction across multiple context and restricted, repetitive pattern of behaviour, interests or activities
– increased from 0.4 per 1,000 in the 1970’s to the current estimate of up to 11.3 per 1,000 (CDC,2007)
– an estimate of 10 to 20 per 10,000 rate for autistic disorder
– affects boys more than girls, M:F ratio of 4:1
–Referred to as the “Fastest growing disability”
Epidemiology…...
– Although no published data on prevalence of autism in Nigeria……
– 1st case of autism in Nigeria reported by Longe (1976), other cases have been reported
(Bello-Mojeed & Omigbodun et al., 2010; Muideen et al, 2008)
– Studies from Child and Adolescent Centre, Yaba, Lagos, point to an increase in number of affected children (Bello-Mojeed & Omigbodun et al., 2009, 2013; Bakare et al, 2012)
– Is there an actual increase or improved recognition?…..
Aetiology…… • no specific aetiological factor for autism
• propounded theories include:
– Genetics
• the most significant of implicated factors
• a complex aetiological concept
• Mutation of gene suggested; the actual mutation that increase risk for autism unidentified
• higher concordance among MZ twins & risk of autism higher in siblings of the affected than the control
Aetiology……
–Family factors
• Suggestion that autism was a response to abnormal parents
• concept of “refrigerator mother”
–Neurological factors-
• associations with some neurological conditions e.g. tuberous sclerosis, congenital rubella,
• Autism is a neuro-developmental disorder!........ Not a “demonic” affliction!!!
• It remains a challenging condition but treatable
• Impact negatively on the child and the family
• Reduction in symptoms and improved level of functioning with treatment, especially when identified early
• Early diagnosis & intervention is key! There is a special ability in this lifelong disability!!!.....About 5% = IQ > 100 !!!
system of care
Conclusions
• ASD is a neuro-developmental disorder
• Begins in early childhood, affect CNS
• Increase in number of children being diagnosed
•
• Recognition of early/warning signs is vital
• Early diagnosis important for intervention
• Early intervention is key
•Service Development for Child & Adolescent Psychiatry
Learning Outcomes: CAMHServices
Participants should:
• Understand the principl e of CAMH Services and system of care framework in Child and Adolescent Psychiatry
• Discuss the process of a community Service development for Child and Adolescent Psychiatry
An Outline
• Sustainable CAMH Services Development
• Principle of CAMH Services
• System of Care frame work
• Community CAMH Services Development
• The Optimal Mix of Services Pyramid
• Core Features of CAMH Services
• Planning Community CAMH Services
• Implementing Direct CAMH Services
• Liaison and Intersectoral CAMH Services
Introduction
• NeuroPsychiatric disorders constitute 14% of the Global Burden of Disease (GBD)
• Mental heath problems have onset in children and adolescent
– About 20% of children and Adolescent experience MH problems
– Huge burden associated with MH problem in children and Adolescents
• 4 of 5 individual with MH problem in LMIC do no receive treatment; mostly child population who rarely initiate help/treatment
• Inadequate CAP service – Development of CAP services is a priority
Sustainable CAMH Services Development
• Compared to Low and Middle Income Countries (LMIC), inter-sectoral CAP system of care are found in High Income Countries (HIC)public sector
•
• Within constraints, CAP service development needs system of care prototype to promote and maintain MH of the African child
• Methods:
– Government: Adoption of CAMH Services
– Implementation of CAMH Service by CAMH professionals in their community
Principles of CAMH Services (WHO)
The WHO Comprehensive Mental Health Action Plan (2013-2020) objectives: To
• strengthen effective leadership and governance for CAMH
• provide comprehensive, integrated and responsive mental health and social care services in community-based settings
•
• implement strategies for preventive and promotion in mental health
• strengthen information systems, evidence and research for mental health
Community CAMH Service Development (WHO, Objective 2)
• Community based mental health care
• Integration of mental health care and treatment into general hospitals and primary care
• Continuity of care between providers and levels of the health system
•
• Effective collaboration between formal and informal care providers
• Promotion of self care
System of Care Framework: Areas of need
• Mental Health Services
• Social Services
• Educational Services
• Health Services
• Substance Abuse Services
• Vocational Services
• Recreational Services
• Operational Services
The Optimal Mix of Service Pyramid, (WHO, 2007)
Core features of CAMH Services • Keep children’s mental health facilities
separate from adults
• Offer services as near to home as possible and in child-centered settings
• Critical mass of staff with sufficient specialists to provide leadership, training and supervision
• Multidisciplinary team approach
• Services must be evidence based
• Coordinate across sectors
CAMH Service
Planning Community CAMH services
• Information/ Data: Conduct epidemiological and ethnographic studies
• Need assessment: Needs of children most at risk
• Situational analysis: of agencies/sectors providing CAMH care
• Model selection: Select an effective service model
• Analysis: Analyze service utilisation and barriers to care
• Opinion: Canvass views of stakeholders
• Priorities: Note national and local priorities
• Scientific evidence: Select evidence based interventions
• Evaluation: Build in outcome evaluation
Implementing Direct CAMH Services
• Advertise the service to all stakeholders
• Build in a good waiting list, booking and record keeping system
• Design an appropriate assessment protocol, maintain adequate clinical notes : diagnosis and management plans
• Ensure that allocated space is dedicated and private and suitable for CAMH work
• Build in regular team meetings and case discussions
• Ensure availability of essential medication
Liaison & Inter-sectoral CAMH Services
• Develop paediatric consultation – liaison services especially in areas of high mental health impact e.g. HIV
• Build on existing service links with other sectors e.g. schools, child welfare, juvenile justice NGO’s
• Provide training and education for other professionals and the public
• Reach out to semi – urban and rural areas
•Legal Considerations in Child & Adolescent Psychiatry
Learning Outcomes...
• Participants should:
• Know existing legal and child mental health legislations in Nigeria
• Understand and discuss important legal Considerations in clinical practice, health research and relevant situations in Child and Adolescent Psychiatry
Outline
• Introduction: Legal and Child Mental Health Legislation in Nigeria
• Convention on the Right of the Child
• Legal Considerations:
– Child Right Act and its violation
– Competence
– Consent
– Confidentiality
– Health Research Ethics e.t.c.
Introduction: Legal and Child Mental Health Legislation in Nigeria
• British Colonial Law (1916): Derivation of existing Mental health legislation
• Lunacy Act (1958): enacted in 1958 as the Lunacy Act, CAP 112, Laws of the Federation of Nigeria; outdated
• No Child Mental Health Act! • The Children and Young Persons Act (CYPA, 1943) • Convention of the Rights of the Child (CRC, 1989)
by the United Nations (UN)
• Organization of African Unity (OAU)’s African Charter on the Rights and Welfare of the Child (ACRWC, 1999)
Convention on the Right of the Child (CRC)
• Children and adolescents have to be viewed and treated as human beings with a distinct set of rights and NOT a passive object of care and charity
• These rights are clearly articulated in the Convention on the rights of the child (CRC, 1990)
• 194 states, including Nigeria ratified CRC
• Domesticated as the Child’s Rights Act (2003)
Core Principles of CRC
• Devotion to the best interests of the child in all actions or decisions
• Non-discrimination on account of race, colour, gender, religion
• A right to life, survival and development in all aspects of their lives: physical, emotional, social, cultural
• Respect for the views of the child
Child Rights Act • Child Right: Human rights of a child
• Examples of Child rights; Right to: • Special protection (e.g. violence) and care
• Human identity
• Basic need for food
• Universal basic education
• Health care
• Equal protection of the child’s civil right e.t.c.
• Though, the best interests of the child must be a primary consideration in all actions or decisions, some rights of the child could be curtailed due to legal considerations such as age and mental capacity
Child Rights Act
• Controversies: – 18 years minimum legal age for marriage
– outlawing of street hawking by children
• At present, in Nigeria, 24 of the 36 states have passed and given gubernatorial assent to CRA; children not being care as required because laws not fully implemented
Child Rights Act: Mental Health Implication
• 41 Articles in Part one of the CRA
• 25 have direct implications (promotion, prevention, treatment and rehabilitation)for the development of child and adolescent mental health policy, services, research and training
• Violation is punishable by appropriate fines or sanctions depending on the state
• Vulnerability of children in research – Age – dependence – social environment – Disability – basic life skill
• Safety of children in research – Informed consent from parents /guardians – Obtain assent from child – Use safe procedures and equipment – Procedures by competent persons – Ensure confidentiality
References
•IACAPAP E - Textbook Of Child and Adolescent Psychiatry iacapap.org/iacapap-textbook-of-child-and-adolescent-mental-health
• Comprehensive Mental Health Action Plan 2013-2020
• Mental Health and Mental Policy and Service Guidance Packae