Attention - Deficit/Hyperactivity Disorder school children
Mental health care in Hanoi
II/Project sites: 16 schools selected from 8 districts of Hanoi : Dong Da, Hai Ba Trung, Hoan Kiem, Ba §inh, Tu Liem, Dong Anh, Soc Son, Thanh Tri.
III/ Project managing board
1. Hanoi Health Service
Number 4 Son Tay Street, Ba Dinh District, Hanoi, Vietnam.
Tel:84.4.7333071
IV/Implementing agency: Mai Huong Daycare Psychiatric Hospital
Address: Number 4 Hong Mai street, Hai Ba Trung district, Hanoi, Vietnam
Phone number and fax: 84.4.6270499
VII/ Timing: 9 months (since early 2009)
Background
Attention-deficit/Hyperactivity Disorder (ADHD) is a syndrome first appearing in childhood that is characterized by abnormal levels of inattention, hyperactivity, or both (Barkley, 1990). Estimates of the prevalence of the disorder in the general childhood-age population run from 3 to 5% (APA, 1994; Barkley, 1990), suggesting that most classrooms may very well have at least one child with ADHD. In fact, because the symptoms associated with attentional disorders appear to be most apparent and problematic in educational settings, ADHD has even been defined as “ a school-based disorder” (Atkins & Pelham, 1991;p. 202), and occurring 3 times more often in boys than in girls.
If ADHD is left untreated, the results of outcome studies of ADHD are very clear. ADHD is a risk factor for many adverse consequences. These range from increased injury rates in childhood, to increased traffic accidents and violations in young adults, to reduced school achievement, to higher rates of school failure, lower self-esteem, early initiation of smoking, lower vocational attainment, higher rates of delinquency and criminal behavior (in those ADHD children with aggression and minor conduct problems), and higher rates of substance abuse. Other adversities relating to ADHD include high rates of depression in parents of children with ADHD and family strain, both economic and emotional. There are data to demonstrate that successful treatment can reduce many of these negative outcomes.
In Vietnam, when a child receives a diagnosis of ADHD, the family may face high out-of-pocket expenses because treatment for ADHD and other mental illness is not covered by insurance policies. School programs (social skills and behaviour training) to help children with problems often connected to ADHD are not available. Also, not all children with ADHD qualify for special education services. All of this leads to children who do not receive proper and adequate treatment.
The administration of psycho-stimulant medication is the least costly option, and it has positive effects in a short period of time (Klassen, Miller, Raina, Lee and Olsen, 1999; Mirenda, Pastor, Rosellã amd Mulas, 1996; Pellham, Wheeler and Chronis, 1998). Recently, epidemiological studies have more precisely defined the prevalence of ADHD and the extent of its treatment with stimulant medication. However, patterns of stimulant use are completely unavailable in Vietnam.
From a public health view, ADHD is a serious disorder with numerous adverse consequences to individuals and society. The cost to society is difficult to estimate, but is considerable. Facilitating access to treatment, reducing barriers, and ensuring the provision of high quality intervention for ADHD should be a public health priority.
Expected outcome
· The study reveals that ADHD is found to be a common problem among school children.
· Adapt the intervention for use in school and professional care settings.
· Greatest concern is the observation the majority of ADHD has received no treatment at all (the proportion of untreated children with ADHD). So future research should help enhance the effectiveness of medical treatments. Better access to care is needed, and barriers to obtaining treatment should be removed.
· In the future, consideration should be given for support to assess the adequacy of current ADHD treatment in the public sector, as well as demonstration models on approaches to install integrated and empirically supported ADHD treatment in existing treatment systems. Given solid evidence on available treatments and promising new advances on the horizons, there is cause for much optimism for help and better future for the citizens of Vietnam affected with ADHD.
Project objectives:
1. To build appropriate screening questionnaire as a tool for Vietnamese children with ADHD.
2. To provide early intervention by establishing the department of behavioral therapy belongs to Mai Huong Hospital which reserves for school children with ADHD.
3. To integrate family, school, and health systems in treating ADHD
4. To identify how common ADHD among school children in some districts. In light of the high prevalence of ADHD in pediatric practice, the study should help school districts plan appropriate interventions, and to provide recommendation to the Ministry of Health (MOH) for implementation on a larger scale and establish a treatment program that recognizes ADHD as a chronic condition.
Method
· Behavioral methods are useful (brain imaging and genetic testing techniques not clinically useful). Specific questionnaires and rating scales are used to review and quantify the behavioral characteristics of ADHD. An Vietnamese questionnaire is used to collect the social demographic variables and a standardized Vietnamese Version of the Conners’ Classroom.
· A large sample of elementary school children (n=2000) participated in this study. We use the CBCL (Child Behavior Checklist) and ARC (Anxiety Rating for Children) as the screening instruments. Diagnoses were determined by clinical psychiatric interviews and confirmed by DSM-IV-based structured interviews.
Description of activities:
Phase 1: Identification of project sites and baseline survey and set up a mechanism of project management
Identification of project sites and baseline survey
Criteria for selection of project sites:
The project sites should meet criteria:
Ø Health and school facilities` leadership has paid attention to and is willing to participate in the project.
Ø The amount of pupils of the school should be suitable to the survey project scale.
Ø The survey will include both urban and suburb sites so that the difference and possibilities of extending of the project could be evaluated.
Mai Huong Daycare Psychiatric Hospital has responsibility of selecting the sites.
16 schools selected from 8 districts of Hanoi will be the sites to implement the project.
Set up a mechanism of project management
a) Project leading board: Consisting of
3. Director of Hanoi Health Service
4. Director of Mai Huong Hospital
This board will be responsible for project implementation.
This board will also be responsible for acting as focus point for collaboration with Vietnam agencies: Ministry of Health, Hanoi People`s Committee, Hanoi Planning and Investment Department, Hanoi Education Service to have their support and direct participation on the project`s activities.
The project leading board will play a general coordinating role for all project activities based upon an agreed plan. The board will meet every 3 months to review the realized activities, and plan activities for the next 3 months period. In case of urgency, the head of project leading board will call an extra- ordinary meeting.
In order to assist to project administrative works, the project leading board will select a project secretary.
b) Project management and steering board (PMSB):
Mai huong Hospital will be the Project`s implementation agency. Mai Huong Hospital will set up a PMSB. Director of Mai Huong Hospital will be project`s deputy director, an economist responsible to project accountant and a project secretary will be assigned.
c)School management team:
Its member consists of health workers, form teachers, parents` groups.
1) A school survey in selected schools:
The research team of Mai Huong Hospital will carry out a survey. The purpose is to identify school children with ADHD in selected schools.
A pre-test to assess the knowledge, attitudes of the parents, teachers, health providers on school children ADHD; Their role in addressing the problem and their needs to provide better supports to the pupils with ADHD. This research tool will also be used in the post - interview survey.
2)Training plan:
In health setting, the research team will conduct a survey and focus group discussions with health providers to identify ADHD; how they usually manage the pupil with ADHD, the collaboration between health sector and educational sector to deal with the problem, and to determine the information and skills health providers need to provide best advice to the children, parents and teachers.
Based on the list of form teachers and parents groups in selected schools, researchers will set up a training plan with the aim of preparation for the intervention. In addition, the project team will review an analyse the existing system of documents, clinic records and statistics of services provided to the school children clients.
Hanoi Health Service and Jansen Clag Company will be involved in the research process by providing comments and inputs on research instruments, sampling methods, contact with local authorities to arrange facilitation during field work.
Phase 2: Conduct the baseline survey
1. Training for form teachers and health providers:
Mai Huong hospital will develop a training curriculum including handout and reading materials to distribute ADHD treatment, the situation in Vietnam and throughout the world, how to support school children with ADHD and counseling skills. Findings of the school survey, information from health providers and other local staff will help draw a comprehensive picture of the practice in the first steps of the process of strengthening the health providers` ability to respond to clients` needs.
The trainer will provide issues related to children with ADHD, real situation and causes, optimum intervention strategies, guidelines and skills of counseling, interpersonal skills that can enhance provider-client relationships. This is one of the components of quality of care that the MOH stressed recently.
2. Development of Vietnamese screening instruments for children school with ADHD:
Following the training is to develop a draft guideline for health providers to identify school children with ADHD. A Mai Huong Hospital working group comprising key health providers will work closely with the project`s consultant to develop and revise guidelines. These health providers will be those who have extensive experience in working with children with ADHD. During conducting series of basic and refresher training, a draft guideline will be presented for participants` suggestions.
The guideline includes basic knowledge of ADHD; how to identify ADHD; intervention; referral list.
The material would be reviewed by the project leading board, the Mai Huong consultant and health providers before being implemented at Mai Huong hospital, commune health facilities.
3. Advocacy plan:
In order to establish a referral list needed as part of a health care service network for school children with ADHD, Mai Huong hospital in collaboration with educational authorities will organize 8 workshops at the 8 district educational offices. Participants will include representatives from local authorities, head masters. The purpose of these workshops is to improve participants` awareness and knowledge of ADHD issue; discuss a plan of collaboration between the mental health specialist, teachers, parents and commune health facilities to establish a support network for addressing ADHD problem among school children.
Organizers will also present to participants the findings of the pre-test and the model "school children ADHD care"
Mai Huong Hospital will set up a plan of providing psycho-therapy for school children with ADHD and their family every month.
Besides workshops, Mai Huong Hospital will collaborate with the media (Hanoi T.V and Radio Station) to sensitize the community to school children ADHD and advertise project activities.
To strengthen the accessibility of information to all member of the community, short article will be published in local news. Leaflets of ADHD and ADHD treatment will distribute to clients who visit Mai Huong Hospital and all the workshops participants to draw attentions into ADHD issue.
Phase 3: Establishment of a school children ADHD treatment plan
1. Administrative organization:
In the sixth month of the project, a model ADHD school children treatment network will be set up with 2 rooms belong to Mai Huong Hospital:
· A psycho-therapy room. There will be 2 tables in the working room: one administrative to receive and examine clients and manage records and files and another will be for counseling. The counseling room must ensure the client`s private and secret information.
· A meeting room consist of one big table and lots of chairs reserved for workshops or family training, teacher training …
Director of Mai Huong Hospital will responsible for the activities of the service network.
2. Activities:
An advisory committee of the "ADHD school children mental health care" system headed by the director of Mai Huong Hospital will responsible to manage the system`s operation.
Other members of this committee will include key person from various departments. These members will hold regular case discussions, about clients referred to mental hospital.
Expert will be invited for professional workshops by health workers from commune facilities in complicated cases in order to find out the best solution of treatment toward mental health problems.
All the clients who need professional care must be given detailed record files of disease`s follow-up progress. It is necessary to provide on-going supervision after ending the project in order to support further and help to collect the data of the following 5 to 10 years.
Phase 4: Dissemination workshop:
Following the intervention, Mai Huong Hospital will again conduct a second survey (post-test); similar to base-line survey conducted before intervention (in phase1) to evaluate the effects of the training and guidelines as well as project`s intervention activities. In this phase, similar research instruments developed in the pre-test will be used in order to measure the success of the project, key indicators are the following:
Ø Number of health staff and teachers fully trained
Ø Health providers` knowledge and attitudes to school children ADHD
Ø Proportion of children screened, identified and received interventions
Ø Number of cases of health providers have successfully dealt with
Ø Number of follow-up clients for psychological intervention
Number of identification/Number in base-line survey
Number of school clients cases receiving treatment
Number/proportion of successful case and unsuccessful case
Ø Potential problems during project`s operation
In addition, the post-test will also review the model of school children mental health care network, its success in helping school pupils with ADHD, needs in improving its activities, and lessons learnt.
A dissemination workshop will be conducted to present the result of the project, screening instruments, data of the school survey and plan of ADHD school children treatment. After the workshop, in light of participants’ suggestions and workshop`s recommendation, Mai Huong Hospital will again introduce the project`s activities, evaluate the effectiveness of the supporting works, revise the guidelines and submit them to the Hanoi Health Service`s leadership and the Ministry Of Health.
Managing and monitoring
The project team, project leading board, project management and steering board will also make frequent visits to the health facilities to see how the project is progressing, and assist heath providers to address difficulties while working with school children with ADHD.
Schedule
Phase1: (3 moths: from January to March 2009) will include the following activities:
Ø Set up the project team, visit selected schools and prepare for project implementation
Ø Conduct a baseline survey: develop the research instruments, conduct the training and fieldwork, and apply data analysis
Ø Prepare for training workshops of health providers, headmasters, form teachers, representatives of parents groups
Ø Develop materials, training materials, leaflet
Phase 2: (3 months: from April to September 2009)
Ø Conduct 2 workshop for health providers at schools on how to use the screening instruments in a survey
Ø Give examination, in-depth interviews and complete clients` medical record files
Ø Prepare to set up the intervention network, staff and advisory committee
Phase 3: (1, 5 months: from October to middle of November 2009)
Ø Set up the ADHD school children treatment plan
Ø Conduct workshop
Phase 4: (1,5months: from November to the end of December 2009)
Ø Implement guidelines and ADHD treatment plan
Ø Conduct an valuation survey (post-test): fieldwork, and data analysis
Ø Organize a dissemination workshop
Ø Revise guidelines in light of workshop`s recommendations, and submit it to the HHS and MOH for a large-scale implementation
Ø Write research reports
Project sustainability
Gone are the days when infectious diseases and various other physical illnesses resulted in widespread morbidity and mortality. Young people are now much more likely to become disabled or even died as a result of unrecognized and inadequately treated mental health disorder and their consequences.
Throughout project implementation, awareness on mental health especially school children ADHD of teacher, parents and health providers will be increased. They will further recognize their role and responsibility in managing the issue. Moreover, health providers will be equipped with knowledge, skills and protocols in managing children with ADHD seeking help from clinics. The project should create the right context for recognizing and treating ADHD among school children in a more timely and effective manner with less stigma. By the end of the project, all activities relating to management of children with ADHD will be maintained.
Director, Mai Huong daycare Psychiatric Hospital
Ph.D Ngo thanh hoi
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