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Background & Objective: There are limited data on child mental health needs in our country. Therefore, an epidemiological study to determine the prevalence rates of child and adolescent psychiatric disorders was initiated as a two-centre (Bangalore and Lucknow) study by the Indian Council of Medical Research. It also aimed to study the psychosocial correlates of the psychiatric disorders. We present here the findings of Bangalore Centre., Methods: In Bangalore, 2064 children aged 0-16 yr, were selected by stratified random sampling from urban middle-class, urban slum and rural areas. The screening stage was followed by a detailed evaluation stage. The ICD-10 DCR criteria were used to reach a penta-axial diagnosis., Results: The results indicated a prevalence rate of 12.5 per cent among children aged 0-16 yr. There were no significant differences among prevalence rates in urban middle class, slum and rural areas. The psychiatric morbidity among 0-3 yr old children was 13.8 per cent with the most common diagnoses being breath holding spells, pica, behaviour disorder NOS, expressive language disorder and mental retardation. The prevalence rate in the 4-16 yr old children was 12.0 per cent. Enuresis, specific phobia, hyperkinetic disorders, stuttering and oppositional defiant disorder were the most frequent diagnoses. When impairment associated with the disorder was assessed, significant disability was found in 5.3 per cent of the 4-16 yr group. Assessment of felt treatment needs indicated that only 37.5 per cent of the families perceived that their children had any problem. Physical abuse and parental mental disorder were significantly associated with psychiatric disorders., Interpretation & Conclusion: Prevalence rates of psychiatric morbidity in 0-16 yr old children in India were found to be lower than Western figures. Middle class urban areas had highest and urban slum areas had lowest prevalence rates. The implications for clinical training, practice and policy initiatives are discussed.

Objective: Data on outcome of juvenile onset bipolar disorder is limited. This study examined the course and outcome of bipolar disorder and assessed the rate and predictors of recovery and relapse in a sample of children and adolescents over a 4-5 year period., Method: Twenty-five consecutively ascertained subjects (9-16 years) with a diagnosis of mania (mean duration at intake of 4.6 +/- 3.9 weeks), were comprehensively assessed at baseline and at 6-month intervals using the Diagnostic Interview for Children and Adolescents (revised) (DICA-R), the Missouri Assessment for Genetic Interview in Children (MAGIC), the Young's Mania Rating Scale (YMRS) and the Children's Global Assessment (CGAS). The study phenotype required DSM-IV criteria of mania with elation and/or grandiosity as a criterion to distinguish them from those with attention deficit hyperactivity disorder. Subjects received the standard treatment as prescribed by their primary treating team., Results: During the course of the study period, all 25 subjects (100%) recovered from the index episode. The mean time to recovery was 44 +/- 46 days. The mean duration of follow-up was 51.6 +/- 4.1 months. Sixteen subjects (64%) relapsed after a mean period of 18 +/- 16.4 months. A majority of the relapses (72.4%) were while the subjects were on treatment., Conclusions: Acute juvenile onset mania has a high rate of recovery and low chronicity. The relapse rate was high and most of these occurred in the first 3 years despite aggressive prophylactic treatment. The effectiveness of currently used thymoleptics, in particular lithium, in the prophylaxis of juvenile bipolar disorder needs to be evaluated in controlled studies.

Studies on the naturalistic course of early-onset bipolar disorder are few and studies evaluating the efficacy of pharmacotherapy consist largely of open trials of thymoleptics and neuroleptics on small samples. The current study was undertaken to map the course of the disorder and the prevailing prescribing practice in early-onset bipolar disorder at a child and adolescent psychiatry center in India. A chart review of 139 children and adolescents (<16 years) with a DSM-IV diagnosis of bipolar disorder-mania was performed and the baseline demographic and clinical characteristics, episode characteristics, and treatment and follow-up details were collected and the data analyzed. The index episode remitted in all 133 (96%) subjects for whom the information was available. One hundred twenty-five (90%) subjects received thymoleptics for the index episode, of which lithium was used in 85%. Valproate was the next most commonly used thymoleptic (18%). Eighteen (13%) subjects received combination thymoleptics. Sixty-eight percent received neuroleptics either alone or as adjuncts in the acute phase. During the follow-up period, which ranged from 3 to 56 months (mean +/- SD, 15 +/- 14), 35% of subjects relapsed, 89% within the first 2 years. Twenty-eight percent of subjects relapsed despite being on apparently adequate doses of lithium. The limitations of the study are that it is retrospective in nature, and that structured diagnostic tools and rating scales were not used. We conclude that lithium is the most commonly used thymoleptic in early-onset bipolar disorder. Lithium alone or in combination with neuroleptics appears to have good efficacy in the acute phase of the disorder. The majority of relapses occurred in the first 2 years and the efficacy of currently used thymoleptics in prophylaxis is uncertain.

Juvenile obsessive-compulsive disorder (OCD) has been hypothesized to be different from adult-onset OCD suggesting that juvenile OCD may be a developmental subtype of the disorder. There is some evidence that juvenile OCD may be phenotypically different from juvenile-onset adult OCD. This study examines the phenotypic characteristics of juvenile OCD (current age < or = 18 years, n = 39), juvenile-onset adult OCD (onset < or = 18 years, current age >18 years, n = 87) and adult-onset OCD (onset > 18 years, n = 105). Qualified psychiatrists expert in evaluating OCD subjects conducted clinical and structured interviews. In the multinomial logistic regression analysis, controlling for chronological age and gender, the juvenile OCD was associated with male preponderance, elevated rates of certain obsessive-compulsive symptoms, attention-deficit hyperactivity disorder, chronic tics, body dysmorphic disorder and major depression. In addition, juvenile-onset adult OCD differed from juvenile OCD by having later age-at-onset and low rate of ADHD. The juvenile-onset adult OCD was positively associated with social phobia and chronic tics compared to adult-onset OCD. The juvenile OCD appears to be different from both juvenile-onset adult OCD and adult-onset OCD supporting previous observations that juvenile OCD could be a developmental subtype of the disorder.

The relationship between obsessive-compulsive disorder (OCD) and putative obsessive-compulsive (OC) spectrum disorders is unclear. This study investigates the prevalence of putative OC spectrum disorders in OCD subjects in a controlled clinical design. The putative OC spectrum disorders studied included somatoform disorders (body dysmorphic disorder [BDD] and hypochondriasis), eating disorders, tic disorders (e.g., Tourette's syndrome [TS]), and impulse control disorders (e.g., trichotillomania). Only those disorders that are commonly noted to be possibly related to OCD are studied. Included in this study were 231 subjects with a diagnosis of OCD according to DSM-IV criteria and 200 controls who were not screened for psychiatric morbidity. The subjects and controls were assessed in detail by extensive clinical and semistructured interviews by expert clinical psychiatrists. The lifetime diagnoses were made by consensus of two psychiatrists. Prevalence of tic disorders, hypochondriasis, BDD, and trichotillomania was significantly greater in OCD subjects compared to controls. However, the prevalence of sexual compulsions, pathological gambling, eating disorders, and depersonalization disorder was not greater in the OCD subjects compared to controls. The findings of this comorbidity study suggest that tic disorders, hypochondriasis, BDD, and trichotillomania are perhaps part of the OC spectrum disorders. There is a need to evaluate evidence from other sources such as epidemiological, neurobiological, and family studies to further our understanding of the concept of OC spectrum disorders.

Objective: To study the long-term course and outcome of juvenile obsessive-compulsive disorder (OCD)., Method: Two to 9-year follow-up of largely self-referred, drug-naïve subjects (n = 58) by employing catch-up longitudinal design., Results: The mean follow-up period was 5 years. Nearly three-fourth of the sample was adequately treated with medications. Only 21% of the subjects had clinical OCD at follow-up and 48% were in true remission (no OCD and not on treatment). Earlier age-at-onset was associated with better course and outcome., Conclusion: Juvenile OCD has favorable outcome. Our findings are applicable to psychiatric hospital settings in India and perhaps to the general psychiatric settings in the Western countries. Whether the better outcome in this sample is the result of differing clinical characteristics or because of true cross-cultural variation in the course needs further exploration. It is speculated that early onset OCD could be a subtype of juvenile OCD with better outcome.

Objective: Recent studies of patients with juvenile bipolar disorder report low rates of recovery and high rates of chronicity. However, we lack data on the short-term outcome. This study examines the pattern of recovery from the index episode in an aggressively treated juvenile sample., Method: We assessed 25 subjects (< 16 years) with a diagnosis of mania, using the Diagnostic Interview for Children and Adolescents-Revised) (DICA-R), Young Mania Rating Scale (YMRS), and Children's Global Assessment Scale (CGAS) at intake and at 3 and 6 months. We studied the time taken to recover from the index episode, the level of functioning, and the factors predicting them., Results: After 6 months, 24 (96%) subjects had recovered from the index manic episode. The median time to recovery was 27 days. Total episode length was significantly longer among those with previous affective episodes., Conclusions: The findings suggest that juvenile-onset mania has high rates of recovery and low rates of chronicity. These differences from the existing literature need further exploration.

Objectives: To determine whether juvenile obsessive-compulsive disorder (OCD) is familial and whether the rate of Tourette syndrome (TS) and tic disorders is higher among relatives of patients with OCD than among relatives of controls subjects., Method: We assessed first-degree relatives of 35 juvenile OCD probands (aged 16 years or less) and 34 matched, psychiatrically unaffected control subjects, using the Diagnostic Interview for Children and Adolescents-Revised (DICA-R) (unpublished), a Questionnaire for tic disorders, the Children's Version of Leyton's Obsessional Inventory (CV-LOI), and the Children's Version of the Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Similarly, we assessed adult relatives, using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN), Leyton's Obsessional Inventory (LOI), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and a Questionnaire for tic disorders. The diagnoses were determined by consensus, using DSM-III-R criteria. We calculated age-corrected morbid risk, using Weinberg's method., Results: The morbid risk for OCD among the relatives of OCD probands was 4.96%, while none of the relatives of unaffected control subjects had OCD. We did not diagnose TS in any of the relatives of either OCD probands or control subjects. We diagnosed chronic motor tic disorders in only 1 of the relatives of OCD probands, while none of the relatives of control subjects had any tic disorder., Conclusion: Most juvenile cases of OCD are nonfamilial and unrelated to tic disorders, while only a few are familial. There is a need to re-examine the issue of familiality in cases of OCD, as well as its relation to TS, using larger community samples to better understand the hypotheses of familial transmission and comorbidity with tic disorders.

Objective: Bipolar disorder in children and adolescents is less well studied than bipolar disorder in adults. This review addresses issues related to its underdiagnosis, precursors of bipolarity, comorbidity, natural course and treatment., Method: Literature from Medline and other searches, and earlier relevant articles including references from recent review articles on juvenile bipolarity were reviewed., Results: Bipolar disorder in juveniles is underdiagnosed and misdiagnosed on various counts. Few recent studies have reported high rates of comorbid attention deficit and disruptive disorders, prompting some researchers to consider them as probable developmental precursors of juvenile bipolarity. There is also evidence to suggest that some juvenile depression could be pre-bipolar, and that certain temperamental predispositions are probable precursors to bipolarity. Limited data on the natural course and outcome suggest that juvenile bipolar disorder is a highly recurring illness as in adults, and that it is associated with significant functional impairment. The psychopharmacological treatment of juvenile bipolar disorder is remarkably understudied, and treatment is often based on studies of adults., Conclusion: There is a need for epidemiological studies of juvenile bipolar disorder. Similarly, there is an urgent need for the methodologically rigorous studies to establish the efficacy of various antimanic drugs. Finally, issues related to comorbidity and temperamental predispositions to juvenile bipolarity need greater clarity, as they may have important treatment and research implications.

Objective: Using minimal exclusion criteria, to assess systematically the psychiatric comorbidity in children and adolescents with obsessive-compulsive disorder (OCD) and compare the findings with those of previous studies., Method: Fifty-four children and adolescents who satisfied DSM-III-R criteria for OCD were assessed using a structured interview schedule, the Children's version of the Yale-Brown Obsessive Compulsive Scale (CY-BOCS), and the questionnaire for tic disorders. All 54 subjects were recruited from the Child and Adolescent Psychiatry (CAP) services of the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, South India. Diagnoses were determined consensually after a review of all the available data., Results: Comorbidity was found in 69% of the sample: 22% were diagnosed with disruptive disorders; 20% met criteria for mood disorders; 19% had anxiety disorders; and 17% had tic disorders. Only 1 subject had bipolar disorder, and none had psychosis. The rates for individual diagnoses--in particular, the rates for disruptive disorders, bipolar disorder, and psychosis--were considerably lower than those reported in previous studies., Conclusions: Patterns of comorbidity in this study differed from those previously reported. Novel patterns of comorbidity with disruptive disorders, bipolar disorder, and psychosis reported in a few recent studies were not replicated in this study. These differences are probably due to different ascertainment methods. Comorbidity needs to be assessed in large epidemiological samples before definite associations can be made between certain comorbid disorders and juvenile OCD.

Stress and coping in the families caring for their member with mental retardation has recently received worldwide research attention. There is no comprehensive instrument to study these issues in India. This study reports on development and standardization of a new instrument to fill this lacuna. Family Interview for Stress and Coping in Mental Retardation (FISC - MR), a semi-structured interview schedule, was developed as a part of two years prospective study of efficacy of brief family intervention for 157 children with mental retardation (funded by ICMR). The tool consists of 2 sections - one measuring stress (daily care, emotional, social and financial) and the other measuring mediators of stress or coping strategies (awareness, attitudes, expectations, rearing practices and social support). Results indicate moderate to high reliability (internal consistency, inter-rater reliability and test-retest reliability) and validity (factorial, criterion and construct) of the instrument. It is concluded that FISC -MR is a useful, reliable and valid instrument for both clinical and research purposes.

Bipolar disorder in adults is known to run an episodic course. However, little information exists on the long-term naturalistic course of bipolar disorder in juvenile populations. The present study was undertaken with the objectives of (i) documenting the rates of recovery and relapse, (ii) identifying the predictors of recovery and relapse and (iii) assessing the rates of comorbid conditions. A total of 30 subjects with onset of bipolar illness (according to DSM-III-R criteria) in childhood and adolescence were assessed systematically at baseline and 4 to 5 years later. All 30 subjects (100%) had recovered from their index episodes and none had exhibited chronicity. Twenty of the 30 subjects (67%) had relapsed, with most relapses occurring within 2 years of recovery from index episodes. No predictors of recovery and relapse could be identified. Conduct disorder was the only comorbid diagnosis in two subjects (7%). The main implication of our study, in view of the high rates of relapse in the crucial developmental phase of a young individual, is that long-term maintenance medication should be considered in juvenile bipolar patients, even if it is a first episode.

A new instrument is presented which is capable of high resolution acoustic imaging at relatively low frequencies. This approach results in increased complexity of the signal processing required and reduced throughput of the instrument. However, these disadvantages are amply compensated by the ability to create velocity scan images of materials with either high attenuation or low material velocities. These measurements are not possible using traditional/acoustic microscopes. The initial performance of the new instrument is demonstrated using thin samples of shim materials to show that acceptable spatial resolution and highly accurate time delay measurements are possible. An application is then shown using the instrument to evaluate subchondral sclerosis in horse bones. It has been hypothesized that changes in the elastic modulus may be associated with fatigue-induced microdamage. The modulus change may further represent bone damage which precedes the development of microcracking. Thin samples are used to allow complementary microradiography to be performed on the bone slices. Because of the low material velocity, surface wave interference methods (so called V(z) curves) are not well suited for use in some bone samples. The thickness of the samples eliminates the potential for the samples to be evaluated using pulse-echo time delay measurements. The new instrument is thus unique in its ability to create velocity scans of these samples.

Mental retardation due to fragile X syndrome is one of the genetic disorders caused by triplet repeat expansion. CGG repeat involved in this disease is known to exhibit polymorphism even among normal individuals. Here we describe the development of suitable probes for detection of polymorphism in CGG repeat at FMR1 locus as well as the diagnosis of fragile X syndrome. Using these methods polymorphism at the FMR1 locus has been examined in 161 individuals. Ninety eight patients with unclassified mental retardation were examined, of whom 7 were found to have the expanded (CGG) allele at the FMR1 locus. The hybridization pattern for two patients has been presented as representative data.

The short-term in-patent facility of the Child and Adolescent Psychiatry Unit in the National Institute of Mental Health and Neurosciences, Bangalore is described. Its clientele over one year is reviewed. Totally 152 admissions were made. Hysterical neurosis (30.8%), Psychoses (25.2%), Conduct disorder (10.5%) and Hyperkinetic syndrome (9.8%) were the most common diagnoses observed in this population who needed short-term intervention. Average duration of stay was 4-12 weeks. All children were admitted with a parent. In 95.8% of the cases the treatment expenses were borne partially/fully by the hospital. The policy and functioning of the facility is discussed.

Objectives: To see whether classic DSM-III-R criteria for mania are applicable to Indian youngsters and to examine the clinical presentation of mania in an Indian child and adolescent psychiatric sample., Method: Fifty subjects with a diagnosis of functional psychosis as per the definition in ICD-9 were recruited from the population referred during the study period of approximately one year (n = 840) to the Child and Adolescent Psychiatry (CAP) clinic of the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, South India. The subjects were systematically evaluated using a standardized clinical interview and demographic questionnaire and were classified according to DSM-III-R. The subjects who satisfied DSM-III-R criteria for mania formed the sample for this study., Results: Twenty-one subjects received a diagnosis of mania according to DSM-III-R. The most common symptoms of mania included pressure of speech, irritability, elation, distractibility, increased self-esteem, expansive mood, flight of ideas, and grandiose delusions. No subject had comorbid attention-deficit hyperactivity disorder (ADHD). Additionally, 13 (61%) of the 21 manic subjects had delusions and/or hallucinations. The other common symptoms included psychomotor agitation, reduced sleep, anger, temper tantrums, decreased concentration, disobedience, aggression, and hyperactivity., Conclusions: Mania was diagnosable in Indian children and adolescents using classic DSM-III-R criteria. The clinical profile appears to be generally similar to that seen in adults. ADHD is not a comorbid condition. The presence of aggressive or disruptive behaviours and hyperactivity in childhood- and adolescent-onset mania, however, could lead to a misdiagnosis of attention-deficit hyperactivity disorder/conduct disorder (ADHD/CD). Similarly, the presence of psychotic features could lead to a misdiagnosis of schizophrenia.

Early detection has a central role in the prevention and management of mental retardation. The purpose of this present study is to delinerate the characteristics of developmentally delayed infants and their families attending Mental Retardation Clinic. The sample consisted of 101 infants who were registered in Mental Retardation Clinic of NIMHANS, Bangalore in 1988 constituting 12.5% of total registrations. Data was collected from case records. Majority of subjects were males, first or second born, 7 months or older, from a consanguineous lower or middle class family. Along with developmental delay, 60% had other complaints. Medical problems were reported in about half of the subjects and most had abnormalities on physical examination. Aetiology was discernible in 77.1%. Majority had associated physical disorder such as cerebral palsy, seizures and hearing and/or visual impairment. Around 17% came for follow-up thrice or more, 43% dropped out after work-up. The main conclusions are that; (i) certain socio-demographic, personal and clinical variables influence treatment seeking, and (ii) developmental delay recognised in infancy tends to be associated with clear aetiologic factors and significant medical/neurologic problems.

A formal, mandatory psychotherapy training programme for psychiatry residents at NIMHANS was started in 1983. It has made qualitatively encouraging progress. It has also focussed on issues demanding attention in the years to come. This paper is a descriptive account of the programme.

Objective: This study examined the rate, correlates, and clinical outcome of childhood hysteria in a sample of inpatients in India. For comparison, the rate of this disorder among outpatients was computed., Method: Data were derived from case records of inpatient (n = 143) and outpatient admissions (n = 640) during a 1-year interval at the Child and Adolescent Psychiatry Unit of the National Institute of Mental Health and Neurosciences, Bangalore, South India., Results: The diagnosis of hysteria was made in 30.8% (n = 44) of the inpatient and 14.8% (n = 95) of the outpatient samples. The inpatients with hysteria were mostly postpubertal, their gender distribution was approximately even, and pseudo-seizure was the most frequent presentation. These inpatients had a brief duration of illness at admission and short-term outcome was generally positive., Conclusions: Children with hysterical symptoms form a notable proportion of cases in child guidance and psychiatry clinics in India. It could be that, in this culture, having a "medical" illness is one of the more acceptable means of seeking psychiatric help. The use of a structured and intensive inpatient treatment package appeared to bring about rapid symptom remission. Some of the present findings could be the basis to explore subtypes of childhood hysteria.

Cerebrospinal fluid (CSF) concentrations of the serotonin and dopamine metabolites, 5-hydroxyindoleacetic acid (5HIAA) and homovanillic acid (HVA), respectively, were measured in a group of 17 children with Autistic Disorder (DSM-III-R). The group means observed for 5HIAA (135 +/- 91 nmol/L) and HVA (502 +/- 324 nmol/L) in the autistic children were not significantly different from those seen in the control group of 15 nonneurologically impaired children (5HIAA, 122 +/- 120 nmol/L; HVA 401 +/- 378 nmol/L). These data suggest that consistent, marked alterations in central serotonin and dopamine turnover are not present in the autistic subjects studied. Although studies to date have found little or no alteration in CSF 5-HIAA in autism, the various reports of CSF HVA are not entirely congruent. Although this study is consistent with most previous studies in not finding a group difference in CSF HVA, the possibility of increased CSF HVA in autism cannot be ruled out.

Classification of psychosis in childhood and adolescence has always been controversial due to the possible developmental modulation of symptom expression. Major classificatory systems have no special criteria for children, and recommend the use of adult criteria. Hence, this study aimed to study the nosology of psychosis of childhood and adolescence, using adult criteria (ICD-9, ICD-10 and DSM-III-R). Fifty subjects between the age of 5 and 16 years who met the ICD-9 definition of psychosis were studied using the Intake Sheet for Adolescents: cross-cultural study and the Interview Schedule for Children and Adolescents. Most of the subjects could be classified into one of the major functional psychosis categories, indicating the applicability of adult criteria in children and adolescents.

Two cases of Gilles de la Tourette syndrome from India are presented. The symptomatology of Tourette syndrome is the same as that documented in western populations which suggests biological factors in the aetiology of the syndrome.

This paper describes a retrospective audit of a domiciliary visiting service in adult psychiatry in one district over a six-month period. General practitioners requested urgent assessment visits for three-quarters of the sample population, but were not present when the consultant attended. When the referrals were compared to the official definition of a domiciliary visit, less than a third were considered to fit the criteria. The implications of these findings are discussed.

Earlier, we reported that true hallucinations may present as a conversion symptom. We here reiterate this and suggest that cultural sanction may be one factor that can lead to hallucinations being classified as true in non-psychotic psychiatric states.

The obsessions and compulsions noted in 16 cases of obsessive-compulsive disorder in children were compared to the phenomenology seen in 398 cases during a decade. Less obsessions, more compulsions, more frequent washing and repeating compulsions characterised the childhood group.

While hallucinations are known to occur as conversion symptoms in non-psychotic psychiatric states such as hysteria and grief, there is a lack of distinction between true and pseudo-hallucinations in such cases. We discuss the rationale which has necessitated this distinction, affirm that true hallucinations can occur in non-psychotic states, discuss the characteristics of such hallucinations, and postulate certain factors which may lead to hallucinations in non-psychotic states being judged as "true."