Responsive Research : how trying to meet contextual needs dictated my research agenda  Yanki Yazgan, M.D. Marmara Universi...
New Haven to Istanbul <ul><li>Yale Child Study Center </li></ul><ul><li>1995 </li></ul><ul><li>A clinician/scientist to be...
Among many <ul><li>Donald Cohen </li></ul><ul><li>James Leckman </li></ul><ul><li>Larry Scahill </li></ul>
What I was taught <ul><li>What I was taught about being a clinician and a scientist: </li></ul><ul><li>Have a focus </li><...
Why I have been out of focus during all these years...
First, some facts <ul><li>The child population  of  the world is 2 .7 billion </li></ul><ul><li>In the US, t he population...
40.4 % of Turkish population under age 19 The largest age group (for total, male and female) in Turkey is between 15-19 th...
Why I have been out of focus <ul><li>Viewed as an opinion leader </li></ul><ul><ul><li>Conforms with my “know it all” styl...
When the needs are there... <ul><li>“ The needs are huge, the resources are scarce, and each need seems more important tha...
Have a look at my list of publications <ul><li>1997. CYBOCS reliability and validity: because I have had the interest in O...
1998 <ul><li>The evergrowing ADHD population and my intensive clinical obligations converged in a new research area. In a ...
Molecular genetics and me ?? <ul><li>My intensive work with ADHD and meeting a few enthusiastic moleculer geneticists in I...
Lack of focus? Passivity? <ul><li>The way I led my research agenda may seem some fatalistic passivity, being drifted from ...
The summer of 1999 <ul><li>The year I turned 40 </li></ul><ul><li>I was already a professor at the medical school </li></u...
August 1999   The Marmara Earthquake, 1999
Needs and ends <ul><li>Needs surpass what can be provided for improving mental health of children and adults </li></ul><ul...
Unusual circumstances <ul><li>Unusual circumstances force us to find unusual ways of </li></ul><ul><li>doing what we have ...
Thinking of new ways of helping children and families to improve their mental health <ul><li>A collaborative co-led by Pro...
References Wolmer, Laor and Yazgan ( 2003 ) CAP Clin North Amer   12:363-381 Wolmer, Laor, Dedeoglu, Siev and Yazgan ( 200...
The initial work <ul><li>The original intervention took place in a 320 family rural temporary settlement in the earthquake...
<ul><li>Teachers were trained to redefine their role as educators and leaders, and execute this role. </li></ul>While cond...
“ edutainment” <ul><li>Well planned “entertainment” activities to mobilise the community were part of the  community activ...
activation <ul><li>These activities, not only brought positive mood, but also increased positive expectations, made the pa...
Helpful in reducing sx in medium-to-high risk groups <ul><li>Decreased the prevalence of severe/very severe PTSD from 30% ...
Provided a time period  for symptom free coping
School and family are both the target and media <ul><li>The family, and school, are child’s two most natural support syste...
A disaster model in nondisaster conditions ? <ul><li>Axiom: </li></ul><ul><li>Methods used in disaster times can be extend...
Empowerment of teachers and parents as mental health agents via.. <ul><li>an atmosphere of stimulating cognitive processes...
<ul><li>Although, I did most of my research in response to the arising contextual needs, collaborations helped them to rea...
<ul><li>The question was somewhat linked with the sadness that followed the great losses of the 1999 Earthquakes. </li></u...
Hüzün ( tristesse ) (And we should)  understand the central importance of  hüzün  as a cultural concept conveying wor l dl...
Loss after loss  “ If I am to convey the intensity of the  tristesse  that Istanbul  caused me to feel as a child, I must ...
Poverty?? “ ...  to convey these neighborhoods as traditional, spoiled and untouched by  the West,  Tanpinar  wrote that '...
Depressive sx fewer with higher SES All groups diff  p<.001, anova
Pessimism somewhat higher by age
Another contextual move <ul><li>So the questions were great, but my potential collaborator had to move.  </li></ul><ul><li...
Another contextual need <ul><li>ADHD in schools </li></ul><ul><li>Facing the same problem </li></ul><ul><li>Shortage of qu...
ADHD in community: how to respond to unmet needs, how to best identify who needs most?
<ul><li>How to identify the cases who need help most in a community sample? </li></ul><ul><li>Use parent ratings, teacher ...
<ul><li>As in most instances, Larry Scahill was up to the task of rescuing me in dealing with this hard work.  </li></ul><...
<ul><li>You already know this ! </li></ul>ADHD: a major public health problem
How can the data from these different informants be integrated? <ul><li>In community surveys, the correlation between pare...
<ul><li>DSM-based ratings from parents and teachers have been used in community studies from several countries: </li></ul>...
Case definition <ul><li>Rating scales provide information about symptom count only. </li></ul><ul><li>Using symptom count ...
<ul><li>The primary purpose of the present study is;  </li></ul><ul><li>to examine different approaches to the identificat...
METHOD <ul><li>three public elementary schools in the Marmara University Hospital catchment area in Istanbul.  </li></ul><...
Subjects and Setting <ul><li>Istanbul is the largest city in Turkey with an estimated population of  12.6 million total.  ...
Measures:  demographics <ul><li>Sociodemographic form : parent report </li></ul><ul><li>Child’s birthdate, gender, handedn...
Measures:   Competency Scales <ul><li>Competency Scales : </li></ul><ul><li>3-item parent and teacher-rated scale reflecti...
remember <ul><li>Parental competence scale originally devised for “quick and dirty” data collection from very large sample...
Measures:  SNAP IV Rating Scale <ul><li>SNAP IV Rating Scale </li></ul><ul><li>18-item rating scale derived from DSM-IV cr...
<ul><li>In the current study </li></ul><ul><li>SNAP-IV was completed by  parents  and  teachers   </li></ul><ul><li>The SN...
MAIN QUESTIONS: Symptom count  vs  Symptom count+impairment Parent OR teacher  vs  Parent AND Teacher <ul><li>Prevalence o...
Recruited sample N=3892 Teacher Rating N=3229 Parent Rating N=3229 Usable data N=3110 Usable data N=3131 Declined consent ...
40.7 (9.6 % ) Fathers  36.4 (5.5 % ) Mothers  9.6 (2.3 % ) Children Mean (SD) Age  7 (0.2%) Very high 261 (8.7%) High 2256...
* Age for grades 1-2=6.6 (0.6); for grades 3-4 = 8.6 (0.6); for grades 5-6 =10.6 (0.7); for grades 7-8 = 12.6 (0.7). Paren...
Teacher SNAP IV scores  for children age 7 to 14 years by gender and by grade (N=3110) Scores for boys > scores for girls ...
Boys>girls  teacher>parent <ul><li>Scores for boys > scores for girls ////both parents and teachers. </li></ul><ul><li>Tea...
<ul><li>The mean total teacher-rated SNAP IV score is 0.69  +  0.69 compared to 0.52  +  0.46 rated by parents (p<0.0001) ...
Hyperactivity scores are higher in younger children <ul><li>Hyperactivity scores for boys in the 1st and 2nd grade: </li><...
<ul><li>Correlation of parent and teacher SNAP IV overall (r=0.26), hyperactivity (r=0.23) and inattention (r=0.25) scores...
Due to differences in distribution of scores by informant; <ul><li>To define possible ADHD for each informant: Separate cu...
Perceived Competency Scales <ul><li>Mean score for all 3 scales of parent PCS: 4.06  +  0.72  </li></ul><ul><li>Mean score...
SNAP IV scores according to thresholds on the  parent- and teacher–rated PC S   Children below the established cut offs on...
Probable ADHD  (exceeding threshold on SNAP+PCS) <ul><li>Parent ratings: 117 children (prevalence 3.8%) </li></ul><ul><li>...
Demographic characteristics of probable ADHD cases versus controls  based on parent or teacher ratings after controlling f...
<ul><li>The drop in estimated prevalence using only the SNAP score, from 10% by each informant to roughly 3% when symptoms...
<ul><li>Although the prevalences for either informant by either method (checklist-only and by checklist plus impairment) w...
<ul><li>Inclusion of impairment ratings in this community-based study design added a severity assessment component to the ...
<ul><li>This is the first community-based study in Turkey reporting prevalence of ADHD using both the parents’ and teacher...
Limitations <ul><li>Our sample, although large and representative of the catchment area of a university hospital, was rest...
Edutainment partnership with big business
Not safe... <ul><li>when asked directly about outdoor play, Turkish moms are significantly more likely to report that they...
Across the country <ul><li>SporOMO İle 2004’ten bu yana ziyaret edilen iller </li></ul><ul><ul><li>Kayseri, Eskişehir, Diy...
The activity area C E
“ education and training”
Is there any effect ?
Take home message: <ul><li>we do not yet know about the generalizability of our impressions and limited findings. But: </l...
 
The CSC <ul><li>A place where I had the opportunity to work with the leaders of the field, best clinicians and researchers...
<ul><li>Learned to run and manage an inpatient unit from the nursing staff and social work/family tx group of W1 </li></ul...
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  • This is in accord with some kind of traditional turkish thinking; we never let any inquiry down. That may yield innovative approaches op-lender, op-reader
  • I was known as the leading person in the field of ADHD not because of my immense expertise, but my somewhat slightly more experience of using stimulants in treatment.
  • (for which I had no interest while I was at Yale together with the gurus of the genetics research in developmental disorders).
  • Was i like that while in the US? İt seems that I have tried going beyond what was made available to me? Neuroimaging work that Jim has initiated and supported Brad for developing. I had taken one end of the work, in particular the basal ganglia assymmetry and corpus callosum area in TS and normal individuals. I decided to look for behavioral laterality measures for which I could find almost noone to consult with therefore I went as far as Massachussets, to find marcel kinsbourne as a consultant (with help of Bruce Wexler) and generous support of Jim Leckman and Donald Cohen. Bob schultz was new in the filed and more focuısed on his original work of intelligence, then, if i do not misremember.
  • The importance of nonclinical activities and nonclinical personnel in helping children and families to improve their relationships and life satisfaction. We have accumulated experience during the intervention studies we performed in the disaster affected areas after the 1999 earthquake. We have published our experience extensively, therefore, I will suffice by giving an informal summary of what we learned and how.
  • We accumulated our experience mainly in these circumstances.
  • The change associated with treatment was prevalent as the risk was higher (figure following) Risk. The number of Stressful and traumatic experiences; pretrauma psychiatric and behavioral status the PTS sx increase as the level of risks (such as preexposure sx) increase
  • After 1999, many of he professionals in our group extended the work into nondisaster conditions, that were not much different from the earthquake area in terms of the inadequacy of services, helplessness and pessimism of the parents, and hesitancy of the teachers. School-based interventions are now more widely used, actively sought by educational authorities and local governments, despite the fact that we are again and still much behind the needs arising.
  • School counselors and school psychologists may shift to a supervisory role under difficult circumstances when therapeutic needs surpass the available traditional clinical resources, roles should change Taking responsibility for managing and coordinating the organizational process in collaboration with the mental health team Leading parents and teachers for being mental health agents. In countries where child psychiatrists and other “mental health professionals” are scarce, can we use other community members? Can teachers and parents serve a mediating role for fostering development of the youth Empowering teachers and parents as mental health agents
  • The three schools had a total student population of 3892. Of these, consent was obtained on 3229 (82%). Teacher data was available on 3110 (79%)
  • Scores for boys&gt;scores for girls for both parents and teachers. Teacher scores&gt;parent scores across all age groups and both genders. Gender difference is greater for teachers… Scores for boys&gt;scores for girls for both parents and teachers. Teacher scores&gt;parent scores across all age groups and both genders. Gender difference is greater for teachers…
  • Low level of income seems to have greater association with being identified by teacher (OR=4.43 [2.89-6.77]) compared to being identified by parents (OR=1.75 [1.07-2.85]) Lower education in mothers (OR=4.41 [2.55-7.63]) and lower education in fathers (OR=2.96 [1.85-4.74]) seem to be associated with being identified as probable ADHD by teachers. Parental report on past psychiatric treatment (OR=4.07 [2.44-6.80]) as well as current psychiatric treatment need are associated with being identified by parents (OR=5.61 [3.50-9.01])
  • In addition to sports based Experiential learning opportunities, cognitive educational activities taking advanage of the positive atmosphere created by the joy and fun.
  • an Oprah style celebrity, trained and supervised before and after the “town hall” meetings, where I was present as “the expert guest”, more like a Q and A session. Both of us were already known to the audience well before through the mass media channels. The meeting was followed by two smaller seminars targeting the “opinion leaders” of the local community, a somewhat “training of the trainers” session where I discussed what would be the most frequent questions that can be heard from the parents of children aged 3-14 years. May seem ambitious, but...
  • Responsive Research: how trying to meet contextual needs dictated my research agenda

    1. 1. Responsive Research : how trying to meet contextual needs dictated my research agenda Yanki Yazgan, M.D. Marmara University Faculty of Medicine, Istanbul
    2. 2. New Haven to Istanbul <ul><li>Yale Child Study Center </li></ul><ul><li>1995 </li></ul><ul><li>A clinician/scientist to be </li></ul><ul><li>So many people had a positive impact on my development, (see names on my blog  ) </li></ul>
    3. 3. Among many <ul><li>Donald Cohen </li></ul><ul><li>James Leckman </li></ul><ul><li>Larry Scahill </li></ul>
    4. 4. What I was taught <ul><li>What I was taught about being a clinician and a scientist: </li></ul><ul><li>Have a focus </li></ul><ul><li>Maintain your focus </li></ul><ul><li>Publish around your focus </li></ul>
    5. 5. Why I have been out of focus during all these years...
    6. 6. First, some facts <ul><li>The child population of the world is 2 .7 billion </li></ul><ul><li>In the US, t he population under 18 is 70 million </li></ul><ul><ul><li>c. 8000 child and adolescent psychiatrists in the USA . </li></ul></ul><ul><ul><li>(needed c. 22 , 000 ) </li></ul></ul><ul><li>In Turkey, t he population under 18 is 28 million </li></ul><ul><ul><li>c. 250 child and adolescent psychiatrists in Turkey (plus, c. 2000 generalpsychiatrists, and c. 5000 pediatricians) </li></ul></ul>
    7. 7. 40.4 % of Turkish population under age 19 The largest age group (for total, male and female) in Turkey is between 15-19 that constitutes 10.6 % of the whole community (followed by ages 10-14, 10.1 %; ages 5-9, 9.9 % and 0-4, 9.7 %).
    8. 8. Why I have been out of focus <ul><li>Viewed as an opinion leader </li></ul><ul><ul><li>Conforms with my “know it all” style </li></ul></ul><ul><li>Social Expectation: “ Respond to every question regardless of your interest and knowledge” </li></ul><ul><li>Questions vary depending on the context </li></ul><ul><li>Context is dictated by, seemingly uncontrollable events, such as natural disasters, wars, crises, socioeconomic disparities etc </li></ul>
    9. 9. When the needs are there... <ul><li>“ The needs are huge, the resources are scarce, and each need seems more important than the other” </li></ul><ul><li>making prioritization of one focus even more difficult </li></ul><ul><li>the needs that I have noticed (or brought to my attention) and could not help to not responding. </li></ul><ul><li>So could not keep my focus... </li></ul>
    10. 10. Have a look at my list of publications <ul><li>1997. CYBOCS reliability and validity: because I have had the interest in OCD, I needed the scale. But before going into more detailed study of pediatric OCD in Turkey... </li></ul>
    11. 11. 1998 <ul><li>The evergrowing ADHD population and my intensive clinical obligations converged in a new research area. In a few months, I was known as the leading person in the field of ADHD not because of my immense expertise. </li></ul>
    12. 12. Molecular genetics and me ?? <ul><li>My intensive work with ADHD and meeting a few enthusiastic moleculer geneticists in Istanbul led me toward the genotype association studies </li></ul><ul><li>Anyway, thanks to my geo location, I was able to publish in Molecular Psychiatry in 1999, and in a few other good journals. </li></ul>
    13. 13. Lack of focus? Passivity? <ul><li>The way I led my research agenda may seem some fatalistic passivity, being drifted from one line of research to another. </li></ul><ul><li>Might well be a personal flaw associated with overcuriosity and low level of persistence coupled with high level of distraction? </li></ul><ul><li>Before I could do some soulsearching, it was already the end of the summer of 1999. </li></ul>
    14. 14. The summer of 1999 <ul><li>The year I turned 40 </li></ul><ul><li>I was already a professor at the medical school </li></ul><ul><li>Father of two </li></ul><ul><li>Had a thriving private practice </li></ul><ul><li>disaster </li></ul>
    15. 15. August 1999 The Marmara Earthquake, 1999
    16. 16. Needs and ends <ul><li>Needs surpass what can be provided for improving mental health of children and adults </li></ul><ul><li>New ways of meeting those needs should be sought while making efforts to increase the numbers of highly competent professionals, including CAPs. </li></ul>
    17. 17. Unusual circumstances <ul><li>Unusual circumstances force us to find unusual ways of </li></ul><ul><li>doing what we have always done. </li></ul>
    18. 18. Thinking of new ways of helping children and families to improve their mental health <ul><li>A collaborative co-led by Prof Nathaniel Laor and Leo Wolmer from TelAviv, and by myself from Istanbul, in response to disaster conditions, developed and implemented community based interventions for un-served populations affected by the disaster. </li></ul>
    19. 19. References Wolmer, Laor and Yazgan ( 2003 ) CAP Clin North Amer 12:363-381 Wolmer, Laor, Dedeoglu, Siev and Yazgan ( 2005 ) JCPP 45:1-8
    20. 20. The initial work <ul><li>The original intervention took place in a 320 family rural temporary settlement in the earthquake hit northwestern Turkey. </li></ul><ul><li>Parents were engaged through informal school gatherings and sessions annexed to PTA mtgs. </li></ul>
    21. 21. <ul><li>Teachers were trained to redefine their role as educators and leaders, and execute this role. </li></ul>While conducting the class activation with supervisory support from a mental health team
    22. 22. “ edutainment” <ul><li>Well planned “entertainment” activities to mobilise the community were part of the community activations. </li></ul>
    23. 23. activation <ul><li>These activities, not only brought positive mood, but also increased positive expectations, made the participants feel part of a larger group heading in the direction of improvement, and helped them become active members of their community as parents, teachers and citizens. </li></ul>
    24. 24. Helpful in reducing sx in medium-to-high risk groups <ul><li>Decreased the prevalence of severe/very severe PTSD from 30% to 18 %. </li></ul>
    25. 25. Provided a time period for symptom free coping
    26. 26. School and family are both the target and media <ul><li>The family, and school, are child’s two most natural support systems in which most of the developmental leaps and hesitations take place. </li></ul>
    27. 27. A disaster model in nondisaster conditions ? <ul><li>Axiom: </li></ul><ul><li>Methods used in disaster times can be extended to routine difficult cases, and methods used in difficult cases can be extended to routine noncases. </li></ul>
    28. 28. Empowerment of teachers and parents as mental health agents via.. <ul><li>an atmosphere of stimulating cognitive processes </li></ul><ul><ul><li>(intellectual coping that supports initiatives) </li></ul></ul><ul><li>Transmitting positive expectations </li></ul><ul><ul><li>(concerning the children’s as well as their own capacities and potential) </li></ul></ul>
    29. 29. <ul><li>Although, I did most of my research in response to the arising contextual needs, collaborations helped them to reach their goals. </li></ul><ul><li>Another collaboration that yielded more than originally intended was in 2002. </li></ul>
    30. 30. <ul><li>The question was somewhat linked with the sadness that followed the great losses of the 1999 Earthquakes. </li></ul><ul><li>But, sadness was not a recent phenomenon. </li></ul>
    31. 31. Hüzün ( tristesse ) (And we should) understand the central importance of hüzün as a cultural concept conveying wor l dly failure, listlessness and spiritual suffering .... ... hüzün has been central to Istanbul (say, Turkish) culture, poetry and everyday life over the past two centuries ... “ .. it is a way of looking at life that implicates us all, not only spiritual state but a state of mind that is ultimately as life affirming as it is negating. ” Pamuk, 2000
    32. 32. Loss after loss “ If I am to convey the intensity of the tristesse that Istanbul caused me to feel as a child, I must describe the history of the city following the destruction of the Ottoman Empire, and -even more important- the way this history is reflected in the city's 'beautiful' landscapes and its people. “
    33. 33. Poverty?? “ ... to convey these neighborhoods as traditional, spoiled and untouched by the West, Tanpinar wrote that 'they were ruined, they were poor and wretched' but had 'retained their own style and their own way of life.' (not anymore)
    34. 34. Depressive sx fewer with higher SES All groups diff p<.001, anova
    35. 35. Pessimism somewhat higher by age
    36. 36. Another contextual move <ul><li>So the questions were great, but my potential collaborator had to move. </li></ul><ul><li>I had already begun collecting a somewhat large data set. </li></ul><ul><li>Finished up with that in 2 years. </li></ul><ul><li>Decided to answer a more worldly question </li></ul>
    37. 37. Another contextual need <ul><li>ADHD in schools </li></ul><ul><li>Facing the same problem </li></ul><ul><li>Shortage of qualified personnel </li></ul><ul><li>Hugeness of the needs </li></ul><ul><li>Services obtained by less needy </li></ul><ul><li>More severe cases receive almost none, and do not feel a need </li></ul>
    38. 38. ADHD in community: how to respond to unmet needs, how to best identify who needs most?
    39. 39. <ul><li>How to identify the cases who need help most in a community sample? </li></ul><ul><li>Use parent ratings, teacher ratings or both? </li></ul>A simple question
    40. 40. <ul><li>As in most instances, Larry Scahill was up to the task of rescuing me in dealing with this hard work. </li></ul><ul><li>I am afraid I am out of time to summarize this. </li></ul><ul><li>May be next time... </li></ul>
    41. 41. <ul><li>You already know this ! </li></ul>ADHD: a major public health problem
    42. 42. How can the data from these different informants be integrated? <ul><li>In community surveys, the correlation between parent and teacher ratings is typically small to medium (duPaul GJ, 1991; Cohen et al. 1994; Bussing et al, 2008; Wolraich et al, 2004). </li></ul><ul><li>Parents and teachers often identify a similar rate of children above the diagnostic threshold - but not the same children (Bussing et al, 2008). </li></ul>
    43. 43. <ul><li>DSM-based ratings from parents and teachers have been used in community studies from several countries: </li></ul><ul><li>Sweden (Landgren et al. 1996; Kadesjo and Gillberg, 2001) </li></ul><ul><li>Australia (Gomez et al. 1999) </li></ul><ul><li>Iceland (Magnusson et al. 1999) </li></ul><ul><li>United States (Rowland et al. 2001,) </li></ul><ul><li>Colombia (Pineda et al. 2003) </li></ul><ul><li>Greece (Skounti et al. 2006 ) </li></ul>
    44. 44. Case definition <ul><li>Rating scales provide information about symptom count only. </li></ul><ul><li>Using symptom count only for the case definition results in a higher estimate of prevalence (Wolraich et al, 1998). </li></ul><ul><li>From a public health standpoint, decisions about mental health service needs could be affected by; </li></ul><ul><li>the choice and number of informants </li></ul><ul><li>whether need determination is based on symptom count alone or symptom count plus impairment. </li></ul>
    45. 45. <ul><li>The primary purpose of the present study is; </li></ul><ul><li>to examine different approaches to the identification of children at high risk for ADHD in a school district sample of children in Istanbul, Turkey. </li></ul><ul><li>The second aim is to examine demographic and clinical characteristics that are associated with this high risk sample. </li></ul>The primary purpose
    46. 46. METHOD <ul><li>three public elementary schools in the Marmara University Hospital catchment area in Istanbul. </li></ul><ul><li>parent and teacher ratings on a broad range of behavioral and emotional problems for all children between the ages of 7 and 14 years </li></ul>
    47. 47. Subjects and Setting <ul><li>Istanbul is the largest city in Turkey with an estimated population of 12.6 million total. Of these, 2 million (about 15%) are children between the ages of 7 and 14 years. </li></ul><ul><li>The three participating schools are in predominantly low and middle income neighborhoods in our catchment area </li></ul><ul><li>representative of the district population </li></ul>
    48. 48. Measures: demographics <ul><li>Sociodemographic form : parent report </li></ul><ul><li>Child’s birthdate, gender, handedness </li></ul><ul><li>Number of siblings </li></ul><ul><li>Birth order </li></ul><ul><li>Parents’ current age, level of education, current occupation </li></ul><ul><li>Family income (self-rated as very low, low, average, high, very high) </li></ul><ul><li>Marital status </li></ul><ul><li>Child’s medical history, past mental health intervention and past or current mental health service need. </li></ul><ul><li>Psychiatric family history (depression, suicide attempts, tics, obsessions, ADHD, other) </li></ul><ul><li>Stressful life events over the prior 12 months and their perceived impact on their child </li></ul>
    49. 49. Measures: Competency Scales <ul><li>Competency Scales : </li></ul><ul><li>3-item parent and teacher-rated scale reflecting the child’s perceived competence in the social and academic domains and overall deportment . </li></ul><ul><li>Each domain is rated on a five-point scale with higher scores reflecting greater competence. </li></ul><ul><li>The scores were combined to create a global functioning scale. </li></ul><ul><li>Parental Perceived Competence (PPC) </li></ul><ul><li>Teacher Perceived Competence (TPC) </li></ul>
    50. 50. remember <ul><li>Parental competence scale originally devised for “quick and dirty” data collection from very large samples in the earthquake affected area </li></ul><ul><li>Best predictor of progress after an intervention </li></ul>
    51. 51. Measures: SNAP IV Rating Scale <ul><li>SNAP IV Rating Scale </li></ul><ul><li>18-item rating scale derived from DSM-IV criteria for ADHD </li></ul><ul><li>May be completed by parents or teachers </li></ul><ul><li>9 items for inattention, 9 items for HA/I </li></ul><ul><li>Each item is rated from 0 to 3; </li></ul><ul><li>0 = Not at All 1=Just a Little 2=Quite a Bit 3= Very Much </li></ul>
    52. 52. <ul><li>In the current study </li></ul><ul><li>SNAP-IV was completed by parents and teachers </li></ul><ul><li>The SNAP IV rating was considered complete if at least 16 of the 18 items were scored. </li></ul><ul><li>The items rated were totalled and divided by the number of items present to obtain a per item mean . </li></ul><ul><li>The per item mean score permits direct comparison to recent community surveys in other countries. </li></ul>Filled by parents and teachers
    53. 53. MAIN QUESTIONS: Symptom count vs Symptom count+impairment Parent OR teacher vs Parent AND Teacher <ul><li>Prevalence of possible ADHD (SNAP only for parents, for teachers and for both) </li></ul><ul><li>Prevalence of probable ADHD (SNAP+impairment scores for parents, for teachers and for both) </li></ul>
    54. 54. Recruited sample N=3892 Teacher Rating N=3229 Parent Rating N=3229 Usable data N=3110 Usable data N=3131 Declined consent N=663 Forms returned but incomplete= 98 Nonparticipation N=21 RESULTS Missing data 87+11
    55. 55. 40.7 (9.6 % ) Fathers 36.4 (5.5 % ) Mothers 9.6 (2.3 % ) Children Mean (SD) Age 7 (0.2%) Very high 261 (8.7%) High 2256 (74.9%) Average 365 (12.1%) Low 122 (4.0%) Very low Household income 298 (9.7%) Separated 2774 (90.3%) Living together Marital status 888 (30.0%) University or higher 635 (21.4%) High school 1439 (48.6%) < High school Father’s education 740 (24.8%) University or higher 668 (22.3%) High school 1581 (52.9%) < High school Mother’s education
    56. 56. * Age for grades 1-2=6.6 (0.6); for grades 3-4 = 8.6 (0.6); for grades 5-6 =10.6 (0.7); for grades 7-8 = 12.6 (0.7). Parent SNAP IV scores for children age 7 to 14 years by gender and by grade (N=3110) 0.42 (0.40) 0.41 (0.39) 0.42 (0.37) 0.53 (0.43) Overall 0.42 (0.47) 0.42 (0.47) 0.43 (0.43) 0.58 (0.52) Hyperactivity 0.39 (0.44) 0.39 (0.43) 0.40 (0.42) 0.48 (0.46) Inattention Mean (STD) Mean (STD) Mean (STD) Mean (STD) Scale 345 374 371 353 N G IRLS 0.51 (0.44) 0.59 (0.51) 0.63 (0.52) 0.60 (0.50) Overall 0.48 (0.50) 0.61 (0.58) 0.67 (0.61) 0.65 (0.60) Hyperactivity 0.52 (0.52) 0.57 (0.57) 0.59 (0.55) 0.53 (0.52) Inattention Mean (STD) Mean (STD) Mean (STD) Mean (STD) Scale 371 412 370 374 N BOYS 7 – 8 5 – 6 3 – 4 1 – 2 CHILD’S GRADE *
    57. 57. Teacher SNAP IV scores for children age 7 to 14 years by gender and by grade (N=3110) Scores for boys > scores for girls ////both parents and teachers. Teacher scores > parent scores across all age groups and both genders. Gender difference is greater for teacher reports 0.49 (0.56) 0.49 (0.56) 0.59 (0.73) 0.53 (0.57) Overall 0.36 (0.57) 0.33 (0.57) 0.46 (0.74) 0.35 (0.56) Hyperactivity 0.62 (0.66) 0.64 (0.66) 0.71 (0.83) 0.69 (0.84) Inattention Mean (STD) Mean (STD) Mean (STD) Mean (STD) Scale 350 379 362 338 N GIRLS 0.82 (0.73) 0.77 (0.67) 0.99 (0.75) 0.85 (0.77) Overall 0.68 (0.78) 0.67 (0.75) 0.86 (0.82) 0.73 (0.83) Hyperactivity 0.94 (0.81) 0.87 (0.75) 1.11 (0.85) 0.96 (0.93) Inattention Mean (STD) Mean (STD) Mean (STD) Mean (STD) Scale 379 405 376 352 N BOYS 7 – 8 5 – 6 3 – 4 1 – 2 CHILD’S GRADE
    58. 58. Boys>girls teacher>parent <ul><li>Scores for boys > scores for girls ////both parents and teachers. </li></ul><ul><li>Teacher scores > parent scores across all age groups and both genders. </li></ul><ul><li>Gender difference is greater for teacher reports </li></ul>
    59. 59. <ul><li>The mean total teacher-rated SNAP IV score is 0.69 + 0.69 compared to 0.52 + 0.46 rated by parents (p<0.0001) </li></ul><ul><li>Mean SNAP scores for boys : </li></ul><ul><li>Parent: 0.58 + 0.49 </li></ul><ul><li>Teacher: 0.85 + 0.73 (p<0.0001) </li></ul><ul><li>Mean SNAP scores for girls : </li></ul><ul><li>Parent: 0.44 + 0.40 </li></ul><ul><li>Teacher: 0.52 + 0.60 (p<0.0001).   </li></ul>
    60. 60. Hyperactivity scores are higher in younger children <ul><li>Hyperactivity scores for boys in the 1st and 2nd grade: </li></ul><ul><li>Parents: 0.65  0.60 </li></ul><ul><li>Teachers: 0.73  0.83 </li></ul><ul><li>Hyperactivity scores for those in the 7th and 8th grade: </li></ul><ul><li>Parents: 0.48  0.50 </li></ul><ul><li>Teachers: 0.68  0.78 </li></ul>
    61. 61. <ul><li>Correlation of parent and teacher SNAP IV overall (r=0.26), hyperactivity (r=0.23) and inattention (r=0.25) scores were small to medium range. </li></ul>
    62. 62. Due to differences in distribution of scores by informant; <ul><li>To define possible ADHD for each informant: Separate cut-points for parents and teachers (based on 1.5 SD above population mean) </li></ul><ul><li>The per item clinical threshold for; </li></ul><ul><li>Parents: 1.2 </li></ul><ul><li>Prevalence of possible ADHD: 10.1% [N=299] </li></ul><ul><li>Teachers: 1.7 </li></ul><ul><li>Prevalence of possible ADHD: 10.6% [N=313] </li></ul><ul><li>Exceeding the threshold on BOTH parent and teacher-rated SNAP </li></ul><ul><li>Prevalence of possible ADHD 2.5% [N=71] </li></ul>
    63. 63. Perceived Competency Scales <ul><li>Mean score for all 3 scales of parent PCS: 4.06 + 0.72 </li></ul><ul><li>Mean score of teacher PCS: 3.80 + 0.95 </li></ul><ul><li>Based on these distributions, we established a cut off of 3 for parent-rated PCS and 2.5 for the teacher-rated PCS. </li></ul><ul><li>These thresholds correspond to 1.5 standard deviations below population mean. </li></ul><ul><li>Lower scores indicate impairment on PCS… </li></ul>
    64. 64. SNAP IV scores according to thresholds on the parent- and teacher–rated PC S Children below the established cut offs on the PCS have higher SNAP scores by parents and teachers. 1.77 (0.77) 1.58 (0.78) 1.11 (0.77) 0.58 (0.61) Mean (SD) 85 243 356 2228 N Teacher 1.05 (0.58) 0.78 (0.56) 0.96 (0.58) 0.44 (0.40) Mean (SD) 77 220 346 2153 N Parent Total 1.44 (0.94) 1.20 (0.98) 0.87 (0.87) 0.48 (0.66) Mean (SD) 85 243 356 2228 N Teacher 0.97 (0.70) 0.75 (0.64) 0.91 (0.68) 0.47 (0.48) Mean (SD) 77 220 346 2153 N Parent Hyperactivity 2.10 (0.83) 1.95 (0.87) 1.36 (0.88) 0.67 (0.71) Mean (SD) 85 243 356 2228 N Teacher 1.12 (0.63) 0.81 (0.63) 1.00 (0.64) 0.40 (0.42) Mean (SD) 77 220 346 2153 N Parent Inattention Below cut off by parent & teacher ≤ 2.5 TPC ≤ 3 PPC Above cut off by parent & teacher SNAP Subscale
    65. 65. Probable ADHD (exceeding threshold on SNAP+PCS) <ul><li>Parent ratings: 117 children (prevalence 3.8%) </li></ul><ul><li>Teacher ratings: 118 children (prevalence 3.8%) </li></ul><ul><li>Stricter definition… </li></ul><ul><li>Both parents AND teachers: 20 children (prevalence 0.64%) </li></ul>
    66. 66. Demographic characteristics of probable ADHD cases versus controls based on parent or teacher ratings after controlling for gender (0.0001) 1.08 (0.53, 2.21) 5.61 (3.50, 9.01) Yes vs. No 15.10 Need for Psychiatric treatment 1.12 (0.51, 2.46) 4.07 (2.44, 6.80) Yes vs. No 7.75 (0.0054) Past Psychiatric treatment (0.0103) 2.96 (1.85, 4.74) 1.32 (0.86, 2.00) < high school vs. > high school 6.59 Father’s education (0.0001) 4.41 (2.55, 7.63) 1.12 (0.74, 1.70) < high school vs. > high school 15.74 Mother’s education (0.0036) 4.43 (2.89, 6.77) 1.75 (1.07, 2.85) < average vs. > average 8.47 Income 1.72 (0.88, 3.39) 0.66 (0.31, 1.42) 7-8 vs. 1-2 0.27 (0.11, 0.65) 1.56 (0.82, 2.99) 5-6 vs. 1-2 11.43 (0.0096) 1.11 (0.54, 2.29) 1.04 (0.51, 2.12) 3-4 vs. 1-2 Grade 0.10 (0.03, 0.40) 1.44 (0.77, 2.70) School 2 vs. School 3 18.08 (0.0001) 1.12 (0.46, 2.75) 0.60 (0.32, 1.12) School 1 vs. School 3 School Odds Ratio (95% CI) Odds Ratio (95% CI) Wald test (P-value) b T EACHER ADHD P ARENT ADHD
    67. 67. <ul><li>The drop in estimated prevalence using only the SNAP score, from 10% by each informant to roughly 3% when symptoms score was combined with exceeding threshold on impairment has potential implications for planning mental health services </li></ul>
    68. 68. <ul><li>Although the prevalences for either informant by either method (checklist-only and by checklist plus impairment) were similar, the identified samples did not include the same children. </li></ul>
    69. 69. <ul><li>Inclusion of impairment ratings in this community-based study design added a severity assessment component to the findings which also had an effect on prevalence estimate. </li></ul><ul><li>Reallocation of treatment resources can decrease the problem of unmet need for treatment of ADHD among impaired or serious cases. </li></ul>
    70. 70. <ul><li>This is the first community-based study in Turkey reporting prevalence of ADHD using both the parents’ and teachers’ ratings and defining cases by ADHD symptom severity only or symptom severity plus impairment. </li></ul>
    71. 71. Limitations <ul><li>Our sample, although large and representative of the catchment area of a university hospital, was restricted to one district in Istanbul, therefore findings may not generalize to other regions. </li></ul><ul><li>Absence of a diagnostic interview… </li></ul><ul><li>Lack of objective measures to rate socioeconomic status </li></ul>
    72. 72. Edutainment partnership with big business
    73. 73. Not safe... <ul><li>when asked directly about outdoor play, Turkish moms are significantly more likely to report that they are concerned that their child would be : </li></ul><ul><li>“ unsafe,” 83% TUR; 65% Global </li></ul><ul><li>“ get hurt,” 75% TUR; 57% Global </li></ul><ul><li>“ get sick” 48% TUR; 31% Global </li></ul>
    74. 74. Across the country <ul><li>SporOMO İle 2004’ten bu yana ziyaret edilen iller </li></ul><ul><ul><li>Kayseri, Eskişehir, Diyarbakır, Antalya, Trabzon, Gaziantep, Samsun, Malatya, Denizli, Mersin(2 kere), Konya, Sivas, Ankara, İstanbul, İzmir, Bursa, Edirne, Elazığ, Erzurum, Sakarya </li></ul></ul>participants “1.000.000”
    75. 75. The activity area C E
    76. 76. “ education and training”
    77. 77. Is there any effect ?
    78. 78. Take home message: <ul><li>we do not yet know about the generalizability of our impressions and limited findings. But: </li></ul><ul><li>while waiting for funds, government agencies, international collaborations to provide support for our activities </li></ul><ul><li>We can get aboard on the bandwagon of other agencies of different agendas moving in the same direction that may serve to our goals of improving the community’s understanding and improving child mental health. </li></ul>
    79. 80. The CSC <ul><li>A place where I had the opportunity to work with the leaders of the field, best clinicians and researchers. </li></ul><ul><li>supervision and teaching from Phyllis Cohen, Wayne Downey, Sam Ritvo, Kyle Pruett, Joe Saccio </li></ul><ul><li>clinical work and consultation with/under Linda Mayes, Fred Volkmar, Joe Woolston, Robert King, Melvin Lewis, Steve Marans, Larry Vitulano </li></ul><ul><li>Learned principles of pediatric psychological assessment from Sara Sparrow, Laurie Cardona </li></ul>
    80. 81. <ul><li>Learned to run and manage an inpatient unit from the nursing staff and social work/family tx group of W1 </li></ul><ul><li>Worked together with Bob Schultz, Brad Peterson, Dorothy Grice </li></ul><ul><li>Learned about neuroscience as applied to child psychiatry from James Leckman, Larry Scahill, Paul Lombroso, Flora Vaccarino, David Pauls, and Donald Cohen </li></ul>

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