Child and Adolescent Psychiatry Nepal

CAPN is an initiative to provide quality care to children with developmental and mental health problem.

Our Patners

ACTIVITIES

  • Daily OPD with:
    - Clinical Evaluation
    - Psychodiagnostic testing
    - Psychological methods of management
    - Pharmacological management
  • Research
  • Phone follow up
  • Outreach Clinic

Download or preview our REPORTS

 
 
Final Progress Report 2017

Child and Adolescent Psychiatric Outpatient Clinic at Kanti

Children’s Hospital (KCH)

Progress report, 2017

Dr. Arun Raj Kunwar, M.D.
Child and Adolescent Psychiatrist

Background

Child and adolescent psychiatry (CAP) outpatient clinic has been running within Kanti Children’s Hospital (KCH) since July 21, 2015. Kanti Children Hospital (KCH) is the first and only government run children hospital in Nepal and provides services to children and adolescents at a minimum cost to the most needy population. KCH has been increasingly providing more specialized services to children and CAP is one of the few specialized services that has been running in this hospital. With forty-two percent of the Nepali population under 18 years of age, most of the children with mental health problems are suffering without any help. As the awareness increases about mental health issues in C&A, CAP clinic has seen a gradual increase in number of patient each year.

The goal of our CAP clinic is to develop as a center of excellence in C&A psychiatry. We envision this center to provide comprehensive treatment needed for C&A with any type of mental health problems and develop this center as teaching, learning focal point where we could develop manpower needed to provide services to children with mental health needs. With this vision, this year we have signed contract with KCH to build our own separate building within KCH premises which was inaugurated by the Hon. Health Minister Gagan Thapa on June 4th of this year. (Please see attached photos at the end)

The outpatient clinic is currently running as a collaborating project between CWIN Nepal, FORUT Norway, and KCH. and our goal is to have it permanently and fully run by the Government of Nepal, Ministry of Health / KCH after a 5-years’ period.

Ground Breaking Ceremony at Kanti Children's Hospital for construction of new Child Psychiatry and Multi-Specialty Building by Honorable Minister of Heath and Population Mr. Gagan Kumar Thapa.

Staff of the OPD

The clinic has the following staff:

Dr. Arun Raj Kunwar, M.D. Child and Adolescent Psychiatrist
Dr. Jasmine Ma, M.D. Psychiatrist
Dr. Jaya Regmee, M.D. Psychiatrist
Ms. Narmada Devkota, M.Phil. Clinical Psychologist
Ms. Isha Bista, M.Phil. Clinical Psychologist
Dr. Utkarsh Karki, M.D. Psychiatrist: Presently, 1st year DM trainee at NIMHANS
Dr. Gunjan Dhonju, M.D. Psychiatrist: Presenlty, Postdoctoral Fellowship trainee at NIMHANS

Aims of the OPD

1. To provide psychological and psychiatric assessments, consultation and treatments for children and adolescents with mental health disorders, including those with developmental disorders

2. Liaison with other departments at KCH to provide consultation services for co-morbid diseases.

3. Develop competence of own staff in their assessments, consultation and treatment of patients

4. Conduct and participate in regular academic sessions

5. Provide training of residents in psychiatry/psychology, medical and nursing students from around the country.

6. Research (both epidemiological and clinical)

7. Community outreach programs / preventive work to promote the mental health of C&A.

8. Advocate for inclusion of child mental health within the child health programs of the government of Nepal.

9. Develop the existing clinic into a National Centre of Excellence in C&A Psychiatry

Psychological/Psychiatric Consultation, Assessment and Treatment

The gradual increase in patient visits to the OPD made a total of 3611 in the year 2017, 1449 of whom were for psychological services.
More than 44 % of our cases seen in 2017 have been referred from outside of Kathmandu. Better awareness about the OPD has lead to increasing referrals from other departments of Kanti Children’s Hospital, other general hospitals, NGOs and general public.

Total Patient visits in Child Psychiatry services 

2162 

Total 

Total patient visits for psychological services 

1449 

3611 

Please see details of cases in attached file.

It should be mentioned that our OPD also provides tele-psychiatry services through telephone to children in remote areas. Our aim is to expand this service by use of AV-devices. Details of Tele-psychiatry service is attached at the end

Work flow at our clinic

All new cases are seen along with a family or a guardian. Dr. Regmee manages the initial case allocation and supervision of history taking by the residents posted in the OPD. Detailed history, including history of present illness, past history, family history, developmental and social history, is taken from each client. If there are no residents posted in the OPD, new cases are seen by other team members. All the newly evaluated cases are usually discussed with Dr. Kunwar for input and advice. Diagnoses are formulated after discussions, and treatment is planned in collaboration with the psychologists.

Psychological assessments methods like intelligence tests, projective tests, rating scales for autism, ADHD, depression, anxiety, PTSD and child behavior checklist (CBCL) are routinely done. Relaxation exercises, CBT, Trauma focused CBT, EMDR, behavioral management, parent skills training, supportive therapy and group therapy are the psychotherapeutic techniques routinely done.

Psychotropic drugs are also routinely used as a treatment option with Selective Serotonin Reuptake Inhibitors (SSRI), Selective Serotonin Norepinephrine Reuptake Inhibitors (SSNRI), Tricyclic Antidepressants (TCAs), Second Generation Antipsychotics, Norepinephrine reuptake inhibitors (Atomoxetine), Benzodiazepines, Alpha-agonist (Clonidine).

In coming years we hope to provide ongoing services and hopefully be able to expand services to more needy population.

Electronic Medical Record

The details of patients are being kept in an OPD register manually. We have already decided to move to electronic medical record of patients in order to ease and systematize our clinical work. The layout of the form to be used has been finalized.

We have already initiated a consultation with Daphe Labs (Nepal based Electronic Medical Record Company) for customization of their EMR to our needs. We plan to finalize this by the end of January, 2018. We hope to move to electronic medical record by the end of first quarter of 2018.

Liaison with other Departments at KCH

We regularly provide consultation and supervision to other departments at KCH on how to take care of children who have additional mental health problems along with their existing physical health problems.

Neurology, endocrine and oncology department are the departments that we collaborate with most frequently. The most recent collaboration is with HIV/ART clinic within KCH in the development of disclosure manual for children with HIV. We hope to continue such collaborations further.

Building of Competence of Working team

Staff members are encouraged to follow cases on a longitudinal basis, and to discuss these cases under supervision of Dr. Kunwar. Interesting cases and specific topics are discussed within the team in regular basis.

Specific competence building programs:

1. Cognitive Behavioral Therapy (CBT) training through Skype: Ms. Devkota, is being regularly supervised by a Norwegian clinical psychologist, Professor Annika Melinder (The University of Oslo).

2. Training in Eye Movement, Desensitization and Reprocessing (EMDR): Ms. Devkota has completed this two –part, basic EMDR training conducted by TPO Alliance and EMDR Association Trauma Recovery/Humanitarian Assistance Program (HAP), in collaboration with WHO Nepal. Formal theory class of part two training was completed on October, 2017. Supervision via SKYPE is still ongoing.

3. Ongoing Supervision on Group Therapy: Ms. Devkota and Ms. Bista both have completed training on group therapy and received ongoing supervision that was completed on November, 2017. The supervisor was Ellen Hagemo, Psychiatrist and Group analyst, from Norway.

4. Advance Clinical Assessment and Management of Childhood Anxiety Disorders: Dr. Catalina Perez, a child Psychologist from United State of America has been providing onsite, twice a week clinical supervision since November, 2017 to both Ms. Devkota and Ms. Bista.

5. Play therapy for Special Needs Children: Ms. Devkota has been taking this is online certification course on Play therapy for Special Needs Children being given by National Association for Play Therapy India since September, 2017. It will be completed within June, 2018.

6. Dialectical Behavior Therapy (DBT) one day workshop: Ms. Devkota and Ms. Bista took part on one day workshop on DBT conducted by Peter Warren, Psychologist from Australia at Institute of medicine on 21th of November, 2017.

7. Role of clinician regarding assessment and management of Autism Spectrum Disorder one day workshop: Dr. Ma, Dr. Regmee and Ms. Devkota took part on one day workshop conducted by Eva Nordian, Family Physician, an export of Neurodevelopmental disorder from Sweden and Ms. Carina Pettersson from Swedish Autism Asperger Association on 2nd of December, 2017.

8. Parent Management Interaction Therapy: Ms. Bista is currently taking a 10-hour online training in Parent Management Interaction Therapy which consists of theoretical and practical aspects with multiple examples and video representations.

9. Mindfulness Workshop: Ms. Bista attended a workshop in mindfulness at Samarpan Academy from Kishor Adhikari, Assistant Professor from Christ University, Bangalore on 27th of December.

We are confident that we will have more collaborations in future for the competence building of our staff.

Seminars and Academic programs:

1. Curriculum development in child and adolescent psychiatry in Nepal: Kanti CAP OPD team organized a Focus group discussion on this topic at Kanti Children’s Hospital on 15th October 2017. Please see the attached report.
2. International workshop on Child And Adolescent Mental Health Development in Nepal: Kanti CAP OPD team organized this workshop at Kanti Children’s Hospital, on 18 October. Please see the attached report.
3. Pediatric Psychopharmacology in New Millennium: Kanti CAP OPD along with Psychiatrists’ Association of Nepal organized a workshop on this topic by Prof. Syed Shujat Ali Naqvi from California, USA on December 6th 2017 at Kanti Children’s Hospital.
4. Child Sexual Abuse Prevention: Kanti CAP OPD along with Nepalese Army Wives Association organized an interaction program on this subject on 31 August 2017 at Army Officer Club to the students and teachers of 5 Army schools of Nepal, which included around 400 students.
5. Child Protection Recognition and Response Training: Dr. Ma was one of the trainer of a five days training program on Child Protection Recognition and Response, which was conducted from 29 April to 3 May 2017 to Pediatrics and Nursing staff of Kanti Children’s Hospital and other Medical Colleges of Kathmandu.
6. Second congress of International Developmental Pediatrics Association (IDPA) was conducted from 8 to 10th of December in Mumbai, India. Dr. Regmee with the support of Dr. Hanne Marit Bjørgaas attended the conference to gain a better understanding of worldwide collaboration and research in childhood disability and mental health.
7. Workshop on “Mental Health care plan”: Dr. Regmee attended workshop on mental health care plan conducted by the WHO country office, Nepal and the ministry of health which focused on the need to include child mental health services to health care system.
8. A workshop on “Mental Health in children and families bringing alive skills, abilities and hope”: Dr. Regmee attended this workshop in the 2nd IDPA Congress to explore the scope for collaboration.
9. Continuing Medical Education (CME) at KCH: Regular CMEs have been conducted by this team once a month to provide an opportunity to engage with other departments.
10. Academic Sessions for the Psychology Interns at TUTH: Dr. Kunwar has also been conducting on and off sessions with the psychology MPhil residents on CAP topics.
11. Management of Children in Disaster situation: Dr. Kunwar along with Pediatric Society of Nepal conducted a seminar in Chitwan in this topic on March of 2017.
12. Child Psychiatry in a least developing country: Columbia University Seminar Series on Global Mental Health, Dr. Kunwar was an invited guest lectures who presented on this subject. Organized by Office of the Dean Global Health Initiative, Department of Epidemiology, Columbia Global Mental Health Program, Columbia Psychiatry, and Teacher’s College Global Mental Health Lab, New York, on November 2017.

Training in child psychiatry for Residents in Psychiatry/Psychology from Tribhuvan University Teaching

Hospital (TUTH) and other Residency Programs

The OPD also services as a training site for psychiatry/ psychology residents from TUTH medical college and other medical colleges. They are involved in regular OPD services and academic activities.

Nursing students from various institutions and medical students from Army Hospital also attend the OPD as it is the only site in Nepal that is sufficiently equipped to provide exposure in child and adolescent psychiatry.

Dr. Shikha Upadhaya; Psychiatry Resident, Novel Medical College
Dr. Kenison Shrestha, Psychiatry Resident, TUTH
Mr. Bhupendra Singh Gurung, Psychology Resident, TUTH
Katie Mauldin, Emergency Medical Technician as observer for a week in July

Research and Developmental Work

Our clinic aspires to integrate clinical work and research work from the very start in order to reach a high level of competence.

The following projects have been worked on in 2017:

1. Epidemiological study on emotional and behavioral problems of school going children of different ethnic groups

This is a PhD project in collaboration with the University of Tromsoe, Norway. The candidate is Dr. Jasmine Ma. Dr. Cecilie Javo is her primary supervisor from the University of Tromsoe. Dr. Arun Raj Kunwar and Dr. Pashupati Mahat, PhD are the local supervisors. This is a national based epidemiological study and will provide data on the prevalence and types of problems in the child population of Nepal, 6-18 years. This kind of research is important for the planning and development of services.

  • NHRC approval: The study was approved by Nepal Health Research Council in 5 May 2017.
  • Approval for research study from Ministry of Education was done in 11 May 2017
  • Three districts from the mountain region, 6 districts from middle hills and 6 districts from the terai region and capital city Kathmandu are selected for the study.
  • Seven field supervisors and 30 research assistants for 16 selected districts were selected and training was provided to them on two occasions.
    • first training was conducted in Kathmandu in 23-24 august 2017 for those districts around Kathmandu
    • second training was conducted in Nepalgunj in 6-7 September 2017 for western and far western districts

Dr. Ma has started data collection and it is progressing well.

2. Development and validation of ADHD diagnostic scale for children in Nepal
Narmada Devkota is enrolled in a PhD program at the Tribhuvan University, Kirtipur Nepal. Her research title is “Development and validation of ADHD diagnostic scale for children in Nepal”. Her supervisors are Prof. Sishir Subba, and Dr. Arun Raj Kunwar as expert adviser. The data collection has completed and analysis has started.

3. Longitudinal follow-up of patients receiving psychotropic in Child Psychiatry OPD, Kanti Children’s Hospital

Based on the finalized format for day to day recording of patient details and the addition of a rating scale (Clinical Global Impression) to rate the side effects, improvement and efficacy, this clinical research plans to find out how to improve the use of psychotropic medication in these children and follow them longitudinally to access long term improvement. Dr. Regmee is leading this study and it is still awaiting approval from Institutional Review Board.

Community Outreach Programs

The aims of the outreach programs are to increase awareness and to prevent mental disorders in children and adolescents by intervening at the community level. They increase the realm of our work and strengthen the intended profile of our clinic.

The following community outreach programs were conducted in 2016:

  1. Supportive supervision visits to the CWIN helpline for psychosocial counselors: These are provided to the psychosocial counselors with their clients in CWIN helpline every first Tuesday of the Nepali month.
  2. Tele-psychiatry outreach program: Telephone follow-ups of patients: A telephone follow-up of patients from remote districts who visited our OPD has been started to monitor improvement and manage medication. Please see attached report for further details.
  3. Outreach to Ilam District: Dr. Kunwar and Ms. Bista visited rural villages of Ilam district in collaboration with KF (Karuna Foundation) which helped in identifying and classifying different C&A mental health disability in 74 cases.
  4. School Awareness Courses: Awareness courses on C&A mental health was conducted at
    -Siddhartha Vanasthali Madhamic Vidyalaya, Balaju
    -Santi Vidya Ghriya, Lainchour
    -Saugat School, Kalanki
    -Malpi International School: Dr. Ma also provides consults to teachers on need basis at this school.
  5. Radio program on C&A mental health: Dr Kunwar, Ms. Narmada, Dr Regmee have attended radio programs and you tube channels to talk about mental health issues in C&A to raise awareness.

Advocate for inclusion of child mental health within the child health programs of the government of Nepal

It is not possible to have a sustainable program in child and adolescent mental health in Nepal without the support of the government which requires policy level involvement. Dr. Kunwar has been a part of multiple meetings at the Health Ministry which were participated by The Minister of Health of Nepal, Health Secretary, the academicians in mental health and other stakeholder to advocate for inclusion of child mental health in Nepal.

Incorporating C&A in National Mental Health Policy:
Dr. Kunwar is also part of National Mental Health Policy working group and has advocated to integrate C&A mental health in overall health systems. This has been incorporated in the new policy draft and awaiting approval from the Government of Nepal.

Child and Adolescent Psychiatry Education

  • Two Psychiatrist sent for C&A Psychiatry training to India: We have sent two psychiatrists to get CAP training at NIMHANS, Bengaluru, India. One candidate is enrolled in 3 years DM and one candidate is enrolled in 1 year Fellowship program. Possibility of sending one more candidate is being explored.
  • Ms. Shrijana Adhikari, M.Phil. Clinical Psychologist is currently at NIMHANS, Bengaluru, India for six months training on child psychology starting from January 1st 2018.
  • We are also in discussions with Dr. David Sims, M.D. a child psychiatrist from the U.K. to possibly send a candidate to the U.K for training in CAP. One candidate has already completed part one PLAB exam and will be going to the UK in next couple of months to complete part two of PLAB. If he succeeds in completing above course, he will commence training in CAP in July of 2018.

Ground Breaking Ceremony at Kanti Children's Hospital for construction of new Child Psychiatry and Multi-Specialty Building by Honorable Minister of Heath and Population Mr. Gagan Kumar Thapa.

We had been in discussion with KCH to build our own building to expand our department. This year we have signed contract with KCH to build our own separate building within KCH premises. KCH will provide needed land and funds will be provided by our collaborating partners. This site was inaugurated by the Hon. Health Minister Gagan Thapa on June 4th of this year. The design phase of the building has been completed and detail civil work and contracts are being presently worked on.