Brief report: Validity and reliability of the Nigerian Autism Screening Questionnaire.

LAY ABSTRACT: Early intervention for individuals with autism spectrum disorder (ASD) is dependent on reliable methods for early detection. Screening for ASD symptoms is an important strategy in low- and middle-income countries that often lack adequate service infrastructure. This study aims to conduct preliminary evaluation of the psychometric properties of a tool developed and deployed in Nigeria called the Nigerian Autism Screening Questionnaire (NASQ). Results demonstrated that NASQ, when used as a community-based survey, has a clear factor structure with consistent measurement across age and sex, and that scores from below average to well above average are measured reliably. Future research is needed to examine the performance of this tool against confirmatory ASD diagnosis in screening and diagnostic contexts to further understand the utility and applicability of this tool in the resource-limited Nigerian setting.

Excess of non-verbal cases of autism spectrum disorders presenting to orthodox clinical practice in Africa - a trend possibly resulting from late diagnosis and intervention.

OBJECTIVES: Characteristics of children with autism spectrum disorders (ASDs) in Africa are not known because of unavailability of large-scale epidemiological studies in this region. This review explored the age at first presentation to orthodox clinical practice of African children with ASDs and their expressive language ability at presentation. METHODS: A literature search of case series and case reports of ASDs from Africa was done through PubMed/MEDLINE, Google Scholar, African Journals Online (AJOL), and archives of the Nigerian Journal of Psychiatry. Six articles included content relating to age of the child at first presentation to orthodox clinical practice and symptoms at presentation related to expressive language ability and therefore fulfilled the inclusion criteria. Suggestions are made to explain the observations emanating from the review. RESULTS: An excess of non-verbal over verbal cases of ASDs have been presenting to orthodox clinical practice and there is a common denominator of late presentation/diagnosis and in turn late intervention, with most cases presenting for the first time well above 8 years of age. Attempts to explain these observations included low levels of knowledge and awareness about ASDs in Africa; problems with help-seeking behaviour; and lack of mental healthcare facilities and trained personnel. CONCLUSIONS: Enhancement of processes directed at ensuring early diagnosis and interventions, especially interventions aimed at improving speech and language development well and sufficiently early, may bring about a shift in the trend of excess non-verbal cases of ASDs over verbal cases presenting to orthodox clinical practice.

Agreement between clinicians' and care givers' assessment of intelligence in Nigerian children with intellectual disability: 'ratio IQ' as a viable option in the absence of standardized 'deviance IQ' tests in sub-Saharan Africa.

BACKGROUND: There may be need to assess intelligent quotient (IQ) scores in sub-Saharan African children with intellectual disability, either for the purpose of educational needs assessment or research. However, modern intelligence scales developed in the western parts of the world suffer limitation of widespread use because of the influence of socio-cultural variations across the world. This study examined the agreement between IQ scores estimation among Nigerian children with intellectual disability using clinicians' judgment based on International Classification of Diseases, tenth Edition(ICD - 10) criteria for mental retardation and caregivers judgment based on 'ratio IQ' scores calculated from estimated mental age in the context of socio-cultural milieu of the children. It proposed a viable option of IQ score assessment among sub-Saharan African children with intellectual disability, using a ratio of culture-specific estimated mental age and chronological age of the child in the absence of standardized alternatives, borne out of great diversity in socio-cultural context of sub-Saharan Africa. METHODS: Clinicians and care-givers independently assessed the children in relation to their socio-cultural background. Clinicians assessed the IQ scores of the children based on the ICD - 10 diagnostic criteria for mental retardation. 'Ratio IQ' scores were calculated from the ratio of estimated mental age and chronological age of each child. The IQ scores as assessed by the clinicians were then compared with the 'ratio IQ' scores using correlation statistics. RESULTS: A total of forty-four (44) children with intellectual disability were assessed. There was a significant correlation between clinicians' assessed IQ scores and the 'ratio IQ' scores employing zero order correlation without controlling for the chronological age of the children (r = 0.47, df = 42, p = 0.001). First order correlation controlling for the chronological age of the children showed higher correlation score between clinicians' assessed IQ scores and 'ratio IQ' scores (r = 0.75, df = 41, p = 0.000). CONCLUSION: Agreement between clinicians' assessed IQ scores and 'ratio IQ' scores was good. 'Ratio IQ' test would provide a viable option of assessing IQ scores in sub-Saharan African children with intellectual disability in the absence of culture-appropriate standardized intelligence scales, which is often the case because of great diversity in socio-cultural structures of sub-Saharan Africa.

Knowledge about childhood autism and opinion among healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders in Nigeria.

BACKGROUND: In designing programs to raise the community level of awareness about childhood autism in sub-Saharan Africa, it is logical to use the primary healthcare workers as contact point for education of the general public. Tertiary healthcare workers could play the role of trainers on childhood autism at primary healthcare level. Assessing their baseline knowledge about childhood autism to detect areas of knowledge gap is an essential ingredient in starting off such programs that would be aimed at early diagnosis and interventions. Knowledge of the healthcare workers on availability of facilities and law that would promote the required interventions is also important. This study assessed the baseline knowledge about childhood autism and opinion among Nigerian healthcare workers on availability of facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders. METHOD: A total of one hundred and thirty four (134) consented healthcare workers working in tertiary healthcare facilities located in south east and south-south regions of Nigeria were interviewed with Socio-demographic, Knowledge about Childhood Autism among Health Workers (KCAHW) and Opinion on availability of Facilities and Law caring for the needs and rights of children with Childhood Autism and other developmental disorders (OFLCA) questionnaires. RESULTS: The total mean score of participated healthcare workers on KCAHW questionnaire was 12.35 +/- 4.40 out of a total score of 19 possible. Knowledge gap was found to be higher in domain 3 (symptoms of obsessive and repetitive pattern of behavior), followed by domains 1 (symptoms of impairments in social interaction), 4 (type of disorder autism is and associated co-morbidity) and 2 (symptoms of communication impairments) of KCAHW respectively among the healthcare workers. Knowledge about childhood autism (KCA) as measured by scores on KCAHW questionnaire was significantly associated with age group distribution of the healthcare workers, with those age group of fourth decades and above more likely to have higher mean score (p = 0.004) and previous experience of managing children with autism spectrum disorders (ASD) (p = 0.000). KCA showed near significant association with area of specialty, with those healthcare workers in psychiatry compared to pediatrics having higher mean score (p = 0.071) and also with years of working experience of the healthcare workers (p = 0.056). More than half of the healthcare workers subscribed to the opinion that facilities and law caring for the needs and rights of children with childhood autism and other developmental disorders are lacking in Nigeria. CONCLUSION: The correlates of KCA may help in selection of those tertiary healthcare workers that would best fit the role of trainers. It is important to update the knowledge gaps of those healthcare workers who scored low in different domains of KCAHW questionnaire. It is imperative for policy makers in Nigeria to advocate and implement multidisciplinary healthcare service system that would ensure early diagnosis and interventions. Nationally representative baseline epidemiological data that would guide policy and planning are also desirable.

Autism Spectrum Disorders in Nigeria: A Scoping Review of Literature and Opinion on Future Research and Social Policy Directions.

INTRODUCTION: Research about autism spectrum disorder (ASD) in sub-Saharan Africa is sparse and limited. However, research studies coming from Nigeria in West Africa as a country have contributed significantly to the subject of ASD in sub-Saharan Africa. METHODS AND RESULTS: This study is a scoping review of research literature on ASD in Nigeria through June 2017 conducted by searching the key terms autism and Nigeria on PubMed and Google Scholar. Included in the review are works concerning case reports and co-morbidities associated with ASD in Nigeria; prevalence of ASD; genetic study of ASD; clinical characteristics of children with ASD; knowledge and awareness about ASD; socio-cultural factors affecting ASD. Expert opinion on social policy and public health issues affecting ASD in Nigeria are discussed. CONCLUSION: Wide research and intervention gaps are noted and we suggest directions for future research, social policy development, and intervention services for individuals with ASD in Nigeria.

Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis.

OBJECTIVES: A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum. METHODS: Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics. RESULTS: Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased. CONCLUSION: Different interviews may not classify major depression equivalently.

Knowledge about childhood autism among health workers (KCAHW) questionnaire: description, reliability and internal consistency.

BACKGROUND: Knowledge and awareness about childhood autism is low among health workers and the general community in Nigeria and other Sub-Saharan African countries. Poor knowledge and awareness about childhood autism, especially among health workers can compromise early recognition and interventions which had been known to improve prognosis in children with autism. In formulating policy and designing interventions for these children, there is need to develop a reliable tool that can be used in assessing baseline knowledge about childhood autism among health workers and the impact that future continued education and awareness campaign may have on such baseline knowledge. Knowledge about childhood autism among health workers (KCAHW) questionnaire was designed for this purpose. METHODS: The KCAHW questionnaire is a nineteen (19) item self-administered questionnaire that is divided into four domains. KCAHW questionnaires were distributed to fifty (50) psychiatric nurses involved in community mental health services in South-Eastern Nigeria to complete. After two weeks period, the KCAHW questionnaires were re-administered to the same fifty (50) psychiatric nurses to assess their knowledge about childhood autism and to assess the test-retest reliability and internal consistency of this questionnaire. RESULTS: KCAHW questionnaire showed good test-retest reliability when the mean domain and total scores at first and second time administration were compared. The four mean domain scores and the mean total scores at first and second time administration were significantly correlated. The questionnaire also had a good overall internal consistency when the mean scores of the four domains were correlated with mean total scores (Cronbach's alpha = 0.97). CONCLUSION: The KCAHW questionnaire is a reliable tool for assessing knowledge of health workers about childhood autism. It would be a useful tool in improving early recognition of features of autism among affected children in Sub-Saharan African and other developing countries of the world where knowledge and awareness about childhood autism is low.

Distribution of symptoms of post-stroke depression in relation to some characteristics of the vulnerable patients in socio-cultural context.

OBJECTIVE: To determine the distribution of symptoms of post-stroke depression (PSD) in relation to some predisposing factors in an African population. RELEVANCE: Environment is a key determinant of behavior, and varied socio-cultural contexts must have implications for modifiable characteristics (age, duration of the stroke, marital status, type of employment, gender, the location of cerebral lesion and complications) of individuals vulnerable to PSD, which may be targeted to enhance recovery. METHOD: This was a cross-sectional observational study of 50 (22 females and 28 males) stroke survivors (mean age=54.76±8.79 years), at the physiotherapy department, the University of Nigeria teaching hospital, Enugu, selected using convenience sampling technique. Data were collected using Becks Depression Inventory and analyzed using Z-score, Chi-square test and univariate logistic regression, at p<0.05. RESULTS: PSD was more prevalent in females (45.45%); young(100%); middle-age(60%) adults(27-36/47-56 years respectively); living with spouse (45%); left cerebral lesions (40.74%); complications(45%); cold case >3 years(47.05%); self-employed and unemployed (66.67%), respectively. Age was significantly associated with depression (χ2 =4.92,df=1,p=0.03), and was related to the risk of PSD (3.7[1.1-12.0], p=0.03, φ +0.31, φ2=0.1). CONCLUSION: Age could be a risk factor for PSD, which was more prevalent in the elderly than young/middle-age adults, female gender, left cerebral lesion, complications, cold case; those living with a spouse, self-employed and unemployed.

Burden and factors associated with post-stroke depression in East central Nigeria.

OBJECTIVE: To determine the burden and factors associated with post-stroke depression in East central Nigeria. METHOD: We carried out this cross-sectional study of 50 stroke survivors (mean age=54.8 ± 8.8 years), at the physiotherapy Department of the University of Nigeria Teaching Hospital, Enugu. Data were collected using Becks Depression Inventory , it was analyzed using Z-scores, Chi-square test and univariate logistic regression. RESULTS: PSD was more common in females (45.45%); middle-age(60%) adults(27-36/47-56 years respectively); living with spouse (45%); left cerebral lesions (40.74%). Self-employed and unemployed (66.67%), respectively. Age was significantly associated with depression (p=0.03), and was related to the risk ofOR3.7 (95% CI 1.1-12.0 ). CONCLUSION: Age could be a risk factor for PSD, which was more prevalent in the elderly than young/middle-age adults, female gender, left cerebral lesion, complications, cold case; those living with a spouse, self-employed and unemployed.

Improving access to interventions among mothers screened positive for post-partum depression (PPD) at National Programme on Immunization (NPI) clinics in south-western and south-eastern Nigeria - A service development report.

We investigate the possibility of improving access to interventions among mothers screened positive for post-partum depression (PPD) at National Programme on Immunization (NPI) clinics randomly selected from Lagos and Enugu States in south-western and south-eastern Nigeria respectively. The principle of human centred design was employed by engaging the mothers screened positive for PPD to be part of the decision making regarding their further assessment and intervention services. The study brought intervention services to primary healthcare centre at the NPI clinics. Improvement in willingness to seek interventions was observed among the mothers screened positive for PPD in this study when compared to our observation in a previous report, where mothers diagnosed with PPD were referred and requested to visit a mental health facility closer to their NPI clinics for further assessment and interventions (95.2% versus 33.7%). Interventional services for the mothers diagnosed with PPD also impact positively on the growth parameters of their infants on follow-up. Principle of human centred design improved access to intervention services among the mothers and infants studied. NPI clinics at primary healthcare level would provide appropriate forum for early screening of mothers for PPD and interventions in low-resource setting like Nigeria. There would be improvement in maternal and child health coverage if the Nigerian Government can adapt human centred design principles employed in this study nationwide.

Neurodevelopmental delay among children under the age of three years at immunization clinics in Lagos State, Nigeria - Preliminary report.

Late diagnosis and interventions characterize childhood neurodevelopmental disorders in Sub-Saharan Africa. This has negatively impacted on the prognosis of the children with neurodevelopmental disorders. This study examined the prevalence and pattern of neurodevelopmental delays among children under the age of 3 years attending immunization clinics in Lagos State, Nigeria and also affords opportunity of early follow-up and interventions, which had been documented to improve prognosis. The study involved two stage assessments; which consisted of first phase screening of the children for neurodevelopmental delays in immunization clinics at primary healthcare centers Lagos State, Nigeria and second phase which consists of definitive clinical evaluation and follow-up interventions for children screened positive for neurodevelopmental delays. Twenty seven (0.9%) of a total of 3,011 children under the age of 3 years were screened positive for neurodevelopmental delays and subsequently undergoing clinical evaluation and follow-up interventions. Preliminary working diagnoses among these children include cerebral palsy, autism spectrum disorder trait, nutritional deficiency, Down syndrome and Non-specific neurodevelopmental delay with co-morbid seizure disorder accounting for 33.3%, 14.8%, 18.5%, 7.4% and 25.9% respectively. This is a preliminary report that would be followed up with information on medium and long term intervention phase.

Public health and research funding for childhood neurodevelopmental disorders in Sub-Saharan Africa: a time to balance priorities.

Sub-Saharan African (SSA) population consists of about 45% children, while in Europe and North America children population is 10-15%. Lately, attention has been directed at mitigating childhood infectious and communicable diseases to reduce under-five mortality. As the under-five mortality index in Sub-Saharan Africa has relatively improved over the last two decades, more Sub-Saharan African children are surviving beyond the age of five and, apparently, a sizeable percentage of this population would be living with one or more childhood neurodevelopmental disorders (NDD). The distribution of child mental health service resources across the world is unequal. This manifests in the treatment gap of major childhood onset mental health problems in SSA, with the gap being more pronounced for childhood NDD. It is important to balance the public health focus and research funding priorities in Sub-Saharan Africa. We urgently need to define the burden of childhood NDD in the region for healthcare planning and policy formulation.

Introducing depression and developmental screenings into the national programme on immunization (NPI) in southeast Nigeria: an experimental cross-sectional assessment.

OBJECTIVES: This study investigates the possibility of introducing depression and developmental screening tools into the National Programme on Immunization (NPI) in southeast Nigeria. The specific objectives were to determine the prevalence of postpartum depression (PPD) among mothers attending immunization clinics and to assess the association of maternal PPD and infant growth in relation to World Health Organization (WHO) recommendations. METHODS: Four hundred and eight (408) mothers completed the sociodemographic questionnaire and the self-report Edinburgh Postnatal Depression Scale (EPDS). The weights, lengths and head circumferences of their infants were recorded, while the WHO recommended equivalents at 50th percentiles were also recorded for each child. The mothers were then interviewed with the major depressive episode module of Mini International Neuropsychiatric Interview (M.I.N.I.) to make diagnosis of depression. RESULTS: About 24.8% and 15.2% of the mothers were found to be depressed using EPDS and major depressive episode module of M.I.N.I., respectively. It was found that maternal PPD is significantly associated with the growth parameters of weights and lengths of the infants studied but not their head circumference. CONCLUSIONS: NPI may provide appropriate forum for early screening of mothers for PPD and interventions in Nigeria. The NPI would also serve a useful avenue of screening for developmental concerns in Nigerian children.

Attention deficit hyperactivity disorder: a neglected issue in the developing world.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a neglected illness in a developing country. OBJECTIVES: The objectives of this study are to investigate the prevalence and pattern of ADHD among children in a Nigeria. METHODS: A structured self-administered questionnaire was used to collect information from the parents of children (and older children) who attended children outpatients' clinic during the study period. The DSM-IV-TR diagnostic criteria for attention deficit hyperactivity disorder were used. RESULTS: Two hundred and seventy-three (273) out of 282 questionnaires were filled completely, giving a response rate of 96.8%. Nine (9) children fulfilled the stated criteria for ADHD giving a prevalence rate of 3.2%. There is no association between gender and ADHD (P = 0.784). CONCLUSIONS: The prevalence of ADHD in our setting is 3.2%, which is similar to that obtained elsewhere in the world.

The socio-demographic characteristics and patterns of help-seeking among patients with schizophrenia in south-east Nigeria.

A large proportion of psychiatric patients in Nigeria seek help from other sources which ultimately lead to treatment delay. Treatment delay could have deleterious effects on treatment outcome especially for people with schizophrenia. The study aimed to determine the socio-demographic characteristics associated with treatment delay in people with schizophrenia. This was a cross-sectional study of 367 patients with schizophrenia presenting for the first time at a psychiatric hospital. About 76% of them had visited traditional/faith healers as a first treatment option. Long distance and use of traditional healers as first treatment option were associated with treatment delay. There is need for effective community psychiatry service delivery with emphasis on those strategies that can educate, influence, and mobilize communities concerning the aetiology, prevention, early detection, and treatment of mental illness.

Prevalence of autism spectrum disorder among Nigerian children with intellectual disability: a stopgap assessment.

The prevalence of autism spectrum disorder (ASD) among sub-Saharan African children with intellectual disability is about 0.7% more than three decades ago. During this period, the prevalence of ASD has been on the increase worldwide. Studies are not available in recent times addressing epidemiology of ASD among sub-Saharan African children. The present study assessed the prevalence of ASD among Nigerian children with intellectual disability. Forty four children with intellectual disability were assessed for diagnosis of childhood autism based on criteria specified in F84.0 section of International Classification of Diseases, Tenth Edition (ICD-10) Diagnostic Criteria for Research. Five (11.4%) of the children studied met the diagnostic criteria for childhood autism. Male/female ratio was 4:1. There is need for large scale epidemiological studies of ASD among sub-Saharan African children to clearly define the inter-relationship between ASD and intellectual disability in this population and to help in health care policy formulation.

Severity in phenotypic expression of homozygous sickle cell disease (Hb.SS)--does hypermelanotic or hypomelanotic skin status of affected patients play a role?

Abnormal hemoglobin distribution on global map, of which hemoglobin S (Hb.S) accounted for about 80% of the disorders resulting from them are more prevalent in the tropics and sub-tropics. Homozygous sickle cell disease (Hb.SS) is the most common and most severe form of sickle cell disease (SCD) in phenotypic expression. The prevalence and severity in phenotypic expression of SCD had been noted to decrease farther away from the equatorial region, with prevalence rate of sickle cell trait of about 2% and less than 1% in North African coast and South Africa, respectively, compared to about 10-40% in the equatorial region. Controlling for human migration, the distribution of prevalence and severity of SCD tend to correspond with the degree of pigmentation of skin color on global map with areas of hyperpigmentation having the likelihood of higher prevalence and severity, while areas of hypopigmentation are characterized by the reverse. This distribution had been observed to correspond with skin color variation on global map based on Von Luschan's chromatic scale. Empirical observation had also shown that individual homozygous SCD patients who are lighter in skin color tend to manifest a less severe phenotypic expression of the disease condition when compared to those with darker skin color using the yard stick of frequency in sickle cell crises. The hypothesis is; would hypermelanotic or hypomelanotic skin status of individual homozygous SCD patient, if measured objectively by assessing the types and quantity of melanin in individual patient, influence the severity in phenotypic expression of SCD in affected patients. Oculocutaneous albinism (OCA) which is characterized by hypomelanosis is an inherited autosomal recessive disorder like SCD. OCA is also common in the tropics and sub-tropics like SCD. It had been reported that OCA does occur co-morbidly with homozygous SCD. Comparing a group of patients with co-morbid OCA and homozygous SCD with another group with SCD, who do not have OCA on severity of phenotypic expression of SCD could provide a feasible means of testing the hypothesis. If future carefully controlled studies confirm the hypothesis of influence of hypermelanotic or hypomelanotic skin status of the individual patients on severity in phenotypic expression of homozygous SCD, genetic and pharmacological interventions aimed at regulation of melanin production may play a role in alleviating the severity in phenotypic expression of SCD in affected patients.

Association of hypomelanotic skin disorders with autism: links to possible etiologic role of vitamin-D levels in autism?

Vitamin D is crucial for several key physiological processes, including brain development, DNA repair, and regulation of many genes. Much evidence indicates prenatal and early postnatal vitamin-D deficiency increases autism risk, probably through multiple effects, including impaired brain development and increased de novo mutations. High autism rates in several genetically based hypomelanotic skin disorders are puzzling, because ultraviolet-B radiation (UVB) in sunlight acting on skin is a key source of vitamin-D, and lighter skin protects against vitamin-D deficiency, especially at high latitudes. We consider two hypotheses to help explain autism's co-morbidity with hypomelanosis. 1) Because genetic and epigenetic variants that produce hypomelanosis help protect against vitamin-D deficiency, they increase reproductive fitness of individuals who also have other autism risk factors. 2) Hypomelanotic children have increased autism risk because photosensitivity and skin-cancer concerns lead families to excessively reduce children's sun exposure. Hypothesis testing could involve studies comparing genomes, epigenetic markers, skin pigmentation, and vitamin-D levels in autistic individuals with and without hypomelanosis, their relatives and controls. Conducting such studies in samples from regions that differ widely in UVB availability would provide particularly valuable data. Support for either hypothesis would elucidate vitamin-D's role in autism and suggest vitamin-D enhancement may aid treatment and prevention of autism.