responsive research: how trying to meet contextual needs dictated my research agenda

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Responsive ResearchResponsive Research::how trying to meet contextual how trying to meet contextual needs dictated my research needs dictated my research agenda agenda

Yanki Yazgan, M.D.Yanki Yazgan, M.D.Marmara University Faculty of Medicine, Marmara University Faculty of Medicine, IstanbulIstanbul


New Haven to IstanbulNew Haven to Istanbul

Yale Child Study CenterYale Child Study Center 19951995 A clinician/scientist to beA clinician/scientist to be So many people had a positive impact So many people had a positive impact

on my development, (see names on on my development, (see names on my blogmy blog))


Among manyAmong many

Donald CohenDonald Cohen James LeckmanJames Leckman Larry ScahillLarry Scahill


What I was taughtWhat I was taught

What I was taught about being a What I was taught about being a clinician and a scientist:clinician and a scientist:

Have a focusHave a focus Maintain your focusMaintain your focus Publish around your focusPublish around your focus


Why I have been out of Why I have been out of focus during all these focus during all these years...years...


First, some factsFirst, some facts

The child population The child population ofof the world is 2 the world is 2.7 billion.7 billion

In the US, tIn the US, the population under 18 is 70 millionhe population under 18 is 70 million – c. c. 8000 child and adolescent psychiatrists in the 8000 child and adolescent psychiatrists in the USAUSA. . – (needed c.(needed c. 22 22,,000000))

In Turkey,In Turkey, tthe population under 18 he population under 18 is 28 millionis 28 million– c. 250c. 250 child and adolescent psychiatrists in child and adolescent psychiatrists in Turkey (plus, Turkey (plus,

c. 2000 generalpsychiatrists, and c. 5000 pediatricians)c. 2000 generalpsychiatrists, and c. 5000 pediatricians)


40.4 % of Turkish 40.4 % of Turkish population under age 19population under age 19

Age group Total Male FemaleTotal 100 100 1000-4 9,68 9,89 9,475 9 9,96 10,15 9,7810 14 10,14 10,4 9,8915 19 10,63 10,75 10,5220-24 9,87 9,98 9,7525-29 8,69 8,67 8,7230-34 7,39 7,43 7,3435-39 7,16 7,14 7,1840-44 6 6,07 5,9345-49 4,97 4,98 4,9650-54 4,01 3,95 4,0755-59 3,04 2,96 3,1160-64 2,7 2,52 2,8865-69 2,43 2,31 2,5470-74 1,73 1,51 1,9675-79 0,85 0,74 0,9780-84 0,36 0,29 0,4485+ 0,32 0,24 0,4Unknown 0,03 0,04 0,03

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 %).


Why I have been out of Why I have been out of focusfocus Viewed as an opinion leaderViewed as an opinion leader

– Conforms with my “know it all” styleConforms with my “know it all” style Social Expectation: “Social Expectation: “RespondRespond to every to every

questionquestion regardless of your interest and regardless of your interest and knowledge”knowledge”

Questions Questions varyvary depending on the context depending on the context ContextContext is dictated by, seemingly is dictated by, seemingly

uncontrollable events, such as natural uncontrollable events, such as natural disasters, wars, crises, socioeconomic disasters, wars, crises, socioeconomic disparities etcdisparities etc


When the needs are When the needs are there...there... ““The needs are huge, the resources are The needs are huge, the resources are

scarce, and each need seems more scarce, and each need seems more important than the other” important than the other”

making prioritization of one focus even more making prioritization of one focus even more difficultdifficult

the needs that I have noticed (or brought to the needs that I have noticed (or brought to my attention) and could not help to not my attention) and could not help to not responding.responding.

So could not keep my focus...So could not keep my focus...


Have a look at my list of Have a look at my list of publicationspublications 1997. CYBOCS reliability and validity: 1997. CYBOCS reliability and validity:

because I have had the interest in because I have had the interest in OCD, I needed the scale. But before OCD, I needed the scale. But before going into more detailed study of going into more detailed study of pediatric OCD in Turkey...pediatric OCD in Turkey...


19981998

The evergrowing ADHD population The evergrowing ADHD population and my intensive clinical obligations and my intensive clinical obligations converged in a new research area. In converged in a new research area. In a few months, I was known as the a few months, I was known as the leading person in the field of ADHD leading person in the field of ADHD not because of my immense expertise.not because of my immense expertise.


Molecular genetics and Molecular genetics and me ??me ?? My intensive work with ADHD and My intensive work with ADHD and

meeting a few enthusiastic moleculer meeting a few enthusiastic moleculer geneticists in Istanbul led me toward geneticists in Istanbul led me toward the genotype association studiesthe genotype association studies

Anyway, thanks to my geo location, I Anyway, thanks to my geo location, I was able to publish in Molecular was able to publish in Molecular Psychiatry in 1999, and in a few other Psychiatry in 1999, and in a few other good journals.good journals.


Lack of focus? Passivity?Lack of focus? Passivity?

The way I led my research agenda may The way I led my research agenda may seem some fatalistic passivity, being drifted seem some fatalistic passivity, being drifted from one line of research to another.from one line of research to another.

Might well be a personal flaw associated Might well be a personal flaw associated with overcuriosity and low level of with overcuriosity and low level of persistence coupled with high level of persistence coupled with high level of distraction?distraction?

Before I could do some soulsearching, it Before I could do some soulsearching, it was already the end of the summer of 1999.was already the end of the summer of 1999.


The summer of 1999The summer of 1999

The year I turned 40The year I turned 40 I was already a professor at the I was already a professor at the

medical schoolmedical school Father of twoFather of two Had a thriving private practiceHad a thriving private practice disasterdisaster


August 1999August 1999

The Marmara Earthquake, 1999


Needs and endsNeeds and ends

Needs surpass what can be provided Needs surpass what can be provided for improving mental health of children for improving mental health of children and adultsand adults

New ways of meeting those needs New ways of meeting those needs should be sought while making efforts should be sought while making efforts to increase the numbers of highly to increase the numbers of highly competent professionals, including competent professionals, including CAPs. CAPs.


Unusual circumstancesUnusual circumstances

Unusual Unusual circumstances force circumstances force us to find unusual us to find unusual ways ofways of

doing what we have doing what we have always done.always done.


Thinking of new ways of Thinking of new ways of helping children and families helping children and families to improve their mental to improve their mental healthhealth

A collaborative co-led by Prof Nathaniel A collaborative co-led by Prof Nathaniel Laor and Leo Wolmer from TelAviv, and Laor and Leo Wolmer from TelAviv, and by myself from Istanbul, in response to by myself from Istanbul, in response to disaster conditions, developed and disaster conditions, developed and implemented community based implemented community based interventions for un-served populations interventions for un-served populations affected by the disaster. affected by the disaster.


ReferencesReferences

Wolmer, Laor and Yazgan (2003)CAP Clin North Amer 12:363-381

Wolmer, Laor, Dedeoglu, Siev and Yazgan (2005) JCPP 45:1-8


The initial workThe initial work

The original The original intervention took place intervention took place in a 320 family rural in a 320 family rural temporary settlement temporary settlement in the earthquake hit in the earthquake hit northwestern Turkey. northwestern Turkey.

Parents were engaged Parents were engaged through informal through informal school gatherings and school gatherings and sessions annexed to sessions annexed to PTA mtgs.PTA mtgs.


Teachers were trained to Teachers were trained to redefine their role as redefine their role as educators and leaders, educators and leaders, and execute this role.and execute this role.

While conducting the class activation with supervisory support from a mental health team


““edutainment”edutainment”

Well planned “entertainment” activities Well planned “entertainment” activities to mobilise the community were part to mobilise the community were part of the of the community activations.community activations.


activationactivation

These activities, not only brought These activities, not only brought positive mood, but also increased positive mood, but also increased positive expectations, made the positive expectations, made the participants feel part of a larger group participants feel part of a larger group heading in the direction of heading in the direction of improvement, and helped them improvement, and helped them become active members of their become active members of their community as parents, teachers and community as parents, teachers and citizens.citizens.


Helpful in reducing sx in Helpful in reducing sx in medium-to-high risk medium-to-high risk groupsgroups

Decreased the prevalence of severe/very Decreased the prevalence of severe/very severe PTSD from 30% to 18 %.severe PTSD from 30% to 18 %.

2022242628303234363840

Child PTSD Reaction

Index

0 1 2 3 4 5

Risk Factorbefore

after


Provided a time period

for symptom free coping


School and family are both School and family are both the target and mediathe target and media The family, and The family, and

school, are child’s school, are child’s two most natural two most natural support systems in support systems in which most of the which most of the developmental developmental leaps and leaps and hesitations take hesitations take place.place.


A disaster model in A disaster model in nondisaster conditions ?nondisaster conditions ?

Axiom:Axiom:Methods used in Methods used in

disaster times can disaster times can be extended to be extended to routine difficult routine difficult cases, and methods cases, and methods used in difficult used in difficult cases can be cases can be extended to routine extended to routine noncases.noncases.


Empowerment of teachers Empowerment of teachers and parents as mental health and parents as mental health agents via..agents via.. an atmosphere of an atmosphere of

stimulating stimulating cognitive processescognitive processes – (intellectual coping that (intellectual coping that

supports initiatives) supports initiatives)

Transmitting Transmitting positive positive expectationsexpectations – (concerning the (concerning the

children’s as well as children’s as well as their own capacities and their own capacities and potential) potential)


Although, I did most of my research in Although, I did most of my research in response to the arising contextual response to the arising contextual needs, collaborations helped them to needs, collaborations helped them to reach their goals.reach their goals.

Another collaboration that yielded Another collaboration that yielded more than originally intended was in more than originally intended was in 2002.2002.


The question was somewhat linked The question was somewhat linked with the sadness that followed the with the sadness that followed the great losses of the 1999 Earthquakes.great losses of the 1999 Earthquakes.

But, sadness was not a recent But, sadness was not a recent phenomenon.phenomenon.


Hüzün (Hüzün (tristessetristesse))(And we should) understand the central importance of hüzün as a cultural concept conveying worldly 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


Loss after Loss after loss 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. “


Poverty??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)(not anymore)


Depressive sx fewer with Depressive sx fewer with higher SEShigher SES

Total CDI scores according to SES

9

9,5

10

10,5

11

11,5

12

12,5

Low Middle High

SES

CD

I sc

ore

All groups diff p<.001, anova


Pessimism somewhat Pessimism somewhat higher by agehigher by age

ASQ_B7-11 yrs 8.712-15 yrs 9.4

ASQ-B scores according to grades

8.2

8.4

8.6

8.8

9

9.2

9.4

9.6

7-11 yrs 12-15 yrs

grades

sco

res


Another contextual moveAnother contextual move

So the questions were great, but my So the questions were great, but my potential collaborator had to move. potential collaborator had to move.

I had already begun collecting a I had already begun collecting a somewhat large data set.somewhat large data set.

Finished up with that in 2 years.Finished up with that in 2 years. Decided to answer a more worldly Decided to answer a more worldly

questionquestion


Another contextual needAnother contextual need

ADHD in schoolsADHD in schools Facing the same problemFacing the same problem Shortage of qualified personnelShortage of qualified personnel Hugeness of the needsHugeness of the needs Services obtained by less needyServices obtained by less needy More severe cases receive almost More severe cases receive almost

none, and do not feel a neednone, and do not feel a need


ADHD in community:ADHD in community:how to respond to unmet how to respond to unmet needs, how to best needs, how to best identify who needs most?identify who needs most?


How to identify the cases who need How to identify the cases who need help most in a community sample?help most in a community sample?

Use parent ratings, teacher ratings or Use parent ratings, teacher ratings or both? both?

A simple question


As in most instances, Larry Scahill was As in most instances, Larry Scahill was up to the task of rescuing me in up to the task of rescuing me in dealing with this hard work. dealing with this hard work.

I am afraid I am out of time to I am afraid I am out of time to summarize this.summarize this.

May be next time...May be next time...


You already know this !You already know this !

ADHD: a major public health problemADHD: a major public health problem


How can the data from these different How can the data from these different informants be integrated?informants be integrated?

In community surveys, the correlation between In community surveys, the correlation between parent and teacher ratings is typically small to parent and teacher ratings is typically small to

mediummedium (duPaul GJ, 1991; Cohen et al. 1994; Bussing et al, 2008; (duPaul GJ, 1991; Cohen et al. 1994; Bussing et al, 2008;

Wolraich et al, 2004).Wolraich et al, 2004). Parents and teachers often identify a Parents and teachers often identify a

similar rate of children above the similar rate of children above the diagnostic threshold - diagnostic threshold - but not the but not the same childrensame children (Bussing et al, 2008).(Bussing et al, 2008).


DSM-based ratings from parents and DSM-based ratings from parents and teachers have been used in community teachers have been used in community studies from several countries:studies from several countries:

Sweden (Landgren et al. 1996; Kadesjo and Gillberg, 2001)Sweden (Landgren et al. 1996; Kadesjo and Gillberg, 2001) Australia (Gomez et al. 1999)Australia (Gomez et al. 1999) Iceland (Magnusson et al. 1999)Iceland (Magnusson et al. 1999) United States (Rowland et al. 2001,)United States (Rowland et al. 2001,) Colombia (Pineda et al. 2003)Colombia (Pineda et al. 2003) Greece (Skounti et al. 2006Greece (Skounti et al. 2006) )


Case definitionCase definition

Rating scales provide information about symptom Rating scales provide information about symptom count only.count only.

Using symptom count only for the case definition Using symptom count only for the case definition results in a higher estimate of prevalence (Wolraich results in a higher estimate of prevalence (Wolraich et al, 1998).et al, 1998).

From a public health standpoint, decisions about From a public health standpoint, decisions about mental health service needs could be affected by;mental health service needs could be affected by;

the choice and number of informantsthe choice and number of informants whether need determination is based on whether need determination is based on symptom symptom

count alone or symptom count plus count alone or symptom count plus impairment. impairment.


The primary purpose of the present study The primary purpose of the present study is; is;

to examine different approaches to the to examine different approaches to the identification of children at high risk for identification of children at high risk for ADHD in a school district sample of children ADHD in a school district sample of children in Istanbul, Turkey. in Istanbul, Turkey.

The second aim is to examine demographic The second aim is to examine demographic and clinical characteristics that are and clinical characteristics that are associated with this high risk sample. associated with this high risk sample.

The primary purposeThe primary purpose


METHODMETHOD

three public elementary schools in the three public elementary schools in the Marmara University Hospital Marmara University Hospital catchment area in Istanbul. catchment area in Istanbul.

parent and teacher ratings on a broad parent and teacher ratings on a broad range of behavioral and emotional range of behavioral and emotional problems for all children between the problems for all children between the ages of 7 and 14 yearsages of 7 and 14 years


Subjects and SettingSubjects and Setting

Istanbul is the largest city in Turkey with an Istanbul is the largest city in Turkey with an estimated population of 12.6 million total. Of estimated population of 12.6 million total. Of these, 2 million (about 15%) are children between these, 2 million (about 15%) are children between the ages of 7 and 14 years. the ages of 7 and 14 years.

The three participating schools are in The three participating schools are in predominantly low and middle income predominantly low and middle income neighborhoods in our catchment areaneighborhoods in our catchment area

representative of the district populationrepresentative of the district population


Measures:Measures: demographics demographics

Sociodemographic formSociodemographic form: parent report: parent report Child’s birthdate, gender, handednessChild’s birthdate, gender, handedness Number of siblingsNumber of siblings Birth orderBirth order Parents’ current age, level of education, current occupationParents’ current age, level of education, current occupation Family income (self-rated as very low, low, average, high, Family income (self-rated as very low, low, average, high,

very high)very high) Marital statusMarital status Child’s medical history, past mental health intervention and Child’s medical history, past mental health intervention and

past or current mental health service need. past or current mental health service need. Psychiatric family history (depression, suicide attempts, tics, Psychiatric family history (depression, suicide attempts, tics,

obsessions, ADHD, other)obsessions, ADHD, other) Stressful life events over the prior 12 months and their Stressful life events over the prior 12 months and their

perceived impact on their childperceived impact on their child


Measures:Measures: Competency ScalesCompetency Scales

Competency ScalesCompetency Scales:: 3-item parent and teacher-rated scale reflecting the 3-item parent and teacher-rated scale reflecting the

child’s perceived competence in the child’s perceived competence in the socialsocial and and academic academic domains and overall domains and overall deportmentdeportment. .

Each domain is rated on a Each domain is rated on a five-point scalefive-point scale with with higher scores reflecting greater competence. higher scores reflecting greater competence.

The scores were combined to create a global The scores were combined to create a global functioning scale. functioning scale.

Parental Perceived Competence (PPC)Parental Perceived Competence (PPC) Teacher Perceived Competence (TPC)Teacher Perceived Competence (TPC)


rememberremember

Parental competence scale originally Parental competence scale originally devised for “quick and dirty” data devised for “quick and dirty” data collection from very large samples in collection from very large samples in the earthquake affected areathe earthquake affected area

Best predictor of progress after an Best predictor of progress after an intervention intervention


Measures:Measures: SNAP IV Rating SNAP IV Rating ScaleScale

SNAP IV Rating ScaleSNAP IV Rating Scale 18-item rating scale derived from DSM-IV 18-item rating scale derived from DSM-IV

criteria for ADHDcriteria for ADHD May be completed by parents or teachersMay be completed by parents or teachers 9 items for inattention, 9 items for HA/I9 items for inattention, 9 items for HA/I Each item is rated from 0 to 3; Each item is rated from 0 to 3; 0 = Not at All 1=Just a Little 2=Quite a Bit 0 = Not at All 1=Just a Little 2=Quite a Bit

3= Very Much3= Very Much


In the current studyIn the current study SNAP-IV was completed by SNAP-IV was completed by parents parents andand

teachersteachers The SNAP IV rating was considered complete if at The SNAP IV rating was considered complete if at

least 16 of the 18 items were scored. least 16 of the 18 items were scored. The items rated were totalled and divided by the The items rated were totalled and divided by the

number of items present to obtain a number of items present to obtain a per item per item meanmean. .

The per item mean score permits direct comparison The per item mean score permits direct comparison to recent community surveys in other countries.to recent community surveys in other countries.

Filled by parents Filled by parents andand teachers teachers


MAIN QUESTIONS:MAIN QUESTIONS:Symptom count Symptom count vsvs Symptom count+impairment Symptom count+impairment

Parent OR teacher Parent OR teacher vsvs Parent AND Teacher Parent AND Teacher

Prevalence of Prevalence of possiblepossible ADHD (SNAP ADHD (SNAP only for parents, for teachers and for only for parents, for teachers and for both)both)

Prevalence of Prevalence of probableprobable ADHD ADHD (SNAP+impairment scores for parents, (SNAP+impairment scores for parents, for teachers and for both)for teachers and for both)


Recruited sampleN=3892

Teacher RatingN=3229

Parent RatingN=3229

Usable dataN=3110

Usable dataN=3131

Declined consentN=663

Forms returnedbut incomplete=98

NonparticipationN=21

RESULTS

Missing data87+11


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 lowHousehold income

298 (9.7%)Separated

2774 (90.3%)Living togetherMarital status

888 (30.0%)University or higher

635 (21.4%)High school

1439 (48.6%)< High schoolFather’s education

740 (24.8%)University or higher

668 (22.3%) High school

1581 (52.9%)< High schoolMother’s education


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

345374371353N

GIRLS

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


371412370374N

BOYS

7 – 85 – 63 – 41 – 2

CHILD’S GRADE*

* 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)


0.49 (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


350379362338N

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


379405376352N

BOYS

7 – 85 – 63 – 41 – 2

CHILD’S GRADE

Teacher SNAP IV scoresTeacher SNAP IV scores for children age 7 to 14 years by gender and by grade (N=3110) 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


Boys>girls Boys>girls teacher>parentteacher>parent

• 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


The mean total teacher-rated SNAP IV score The mean total teacher-rated SNAP IV score is 0.69 is 0.69 ++ 0.69 compared to 0.52 0.69 compared to 0.52 ++ 0.46 0.46 rated by parents (p<0.0001)rated by parents (p<0.0001)

Mean SNAP scores for Mean SNAP scores for boysboys:: Parent: 0.58 + 0.49Parent: 0.58 + 0.49 Teacher: 0.85 + 0.73 (p<0.0001)Teacher: 0.85 + 0.73 (p<0.0001) Mean SNAP scores for Mean SNAP scores for girlsgirls:: Parent: 0.44 + 0.40Parent: 0.44 + 0.40 Teacher: 0.52 + 0.60 (p<0.0001). Teacher: 0.52 + 0.60 (p<0.0001).


Hyperactivity scores are Hyperactivity scores are higher in younger childrenhigher in younger children

Hyperactivity scores for boys in the 1st Hyperactivity scores for boys in the 1st and 2nd grade:and 2nd grade:

Parents: 0.65 Parents: 0.65 ±± 0.60 0.60 Teachers: 0.73 Teachers: 0.73 ±± 0.83 0.83 Hyperactivity scores for those in the Hyperactivity scores for those in the

7th and 8th grade:7th and 8th grade: Parents: 0.48 Parents: 0.48 ±± 0.50 0.50 Teachers: 0.68 Teachers: 0.68 ±± 0.78 0.78


Correlation of parent and teacher Correlation of parent and teacher SNAP IV overall (r=0.26), hyperactivity SNAP IV overall (r=0.26), hyperactivity (r=0.23) and inattention (r=0.25) (r=0.23) and inattention (r=0.25) scores were small to medium range.scores were small to medium range.


Due to differences in distribution of Due to differences in distribution of scores by informant;scores by informant;

To define possible ADHD for each informant: To define possible ADHD for each informant: Separate cut-points for parents and teachers Separate cut-points for parents and teachers (based on 1.5 SD above population mean)(based on 1.5 SD above population mean)

The per item clinical threshold for;The per item clinical threshold for; Parents: 1.2 Parents: 1.2

Prevalence of possible ADHD: 10.1% [N=299]Prevalence of possible ADHD: 10.1% [N=299] Teachers: 1.7 Teachers: 1.7

Prevalence of possible ADHD: 10.6% [N=313]Prevalence of possible ADHD: 10.6% [N=313] Exceeding the threshold on BOTH parent and Exceeding the threshold on BOTH parent and

teacher-rated SNAPteacher-rated SNAPPrevalence of possible ADHD 2.5% [N=71]Prevalence of possible ADHD 2.5% [N=71]


Perceived Competency ScalesPerceived Competency Scales

Mean score for all 3 scales of parent PCS: Mean score for all 3 scales of parent PCS: 4.06 4.06 ++ 0.72 0.72

Mean score of teacher PCS: 3.80 Mean score of teacher PCS: 3.80 ++ 0.95 0.95 Based on these distributions, we established Based on these distributions, we established

a cut off of 3 for parent-rated PCS and 2.5 a cut off of 3 for parent-rated PCS and 2.5 for the teacher-rated PCS. for the teacher-rated PCS.

These thresholds correspond to 1.5 These thresholds correspond to 1.5 standard deviations below population mean.standard deviations below population mean.

Lower scores indicate impairment on PCS… Lower scores indicate impairment on PCS…


1.77 (0.77)1.58 (0.78)1.11 (0.77)0.58 (0.61)Mean (SD)

852433562228NTeacher

1.05 (0.58)0.78 (0.56)0.96 (0.58)0.44 (0.40)Mean (SD)

772203462153NParent

Total

1.44 (0.94)1.20 (0.98)0.87 (0.87)0.48 (0.66)Mean (SD)


0.97 (0.70)0.75 (0.64)0.91 (0.68)0.47 (0.48)Mean (SD)

772203462153NParent

Hyperactivity

2.10 (0.83)1.95 (0.87)1.36 (0.88)0.67 (0.71)Mean (SD)


1.12 (0.63)0.81 (0.63)1.00 (0.64)0.40 (0.42)Mean (SD)

772203462153NParent

Inattention

Below cut off by parent & teacher

≤ 2.5 TPC ≤3 PPC Above cut off by parent &

teacher

SNAP Subscale

SNAP IV scores according to thresholds on the parent- and teacher–rated PCS

Children below the established cut offs on the PCS have higher SNAP scores by parents and teachers.


Probable ADHD Probable ADHD (exceeding threshold on SNAP+PCS)(exceeding threshold on SNAP+PCS)

Parent ratings: 117 children (prevalence Parent ratings: 117 children (prevalence 3.8%)3.8%)

Teacher ratings: 118 children Teacher ratings: 118 children (prevalence 3.8%)(prevalence 3.8%)

Stricter definition… Stricter definition… Both parents AND teachers: 20 children Both parents AND teachers: 20 children

(prevalence 0.64%)(prevalence 0.64%)

www.yankiyazgan.comwww.yankiyazgan.com 6666(0.0001)1.08 (0.53, 2.21)5.61 (3.50, 9.01)Yes vs. No

15.10Need 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

6.59Father’s education

(0.0001)4.41 (2.55, 7.63)1.12 (0.74, 1.70)< high school vs. > high school

15.74Mother’s education

(0.0036)4.43 (2.89, 6.77)1.75 (1.07, 2.85)< average vs. > average

8.47Income

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. 1-211.43

(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

TEACHER ADHDPARENT ADHD

Demographic characteristics of probable ADHD cases versus controls based on parent or teacher ratings after controlling for gender


The drop in estimated prevalence The drop in estimated prevalence using only the SNAP score, from 10% using only the SNAP score, from 10% by each informant to roughly 3% by each informant to roughly 3% when symptoms score was combined when symptoms score was combined with exceeding threshold on with exceeding threshold on impairment has potential implications impairment has potential implications for planning mental health services for planning mental health services


Although the prevalences for either Although the prevalences for either informant by either method (checklist-informant by either method (checklist-only and by checklist plus impairment) only and by checklist plus impairment) were similar, the identified samples did were similar, the identified samples did not include the same children.not include the same children.


Inclusion of impairment ratings in this Inclusion of impairment ratings in this community-based study design added a community-based study design added a severity assessment component to the severity assessment component to the findings which also had an effect on findings which also had an effect on prevalence estimate. prevalence estimate.

Reallocation of treatment resources can Reallocation of treatment resources can decrease the problem of unmet need for decrease the problem of unmet need for treatment of ADHD among impaired or treatment of ADHD among impaired or serious cases.serious cases.


This is the first community-based This is the first community-based study in Turkey reporting prevalence study in Turkey reporting prevalence of ADHD using both the parents’ and of ADHD using both the parents’ and teachers’ ratings and defining cases by teachers’ ratings and defining cases by ADHD symptom severity only or ADHD symptom severity only or symptom severity plus impairment. symptom severity plus impairment.


LimitationsLimitations

Our sample, although large and Our sample, although large and representative of the catchment area of a representative of the catchment area of a university hospital, was restricted to one university hospital, was restricted to one district in Istanbul, therefore findings may district in Istanbul, therefore findings may not generalize to other regions.not generalize to other regions.

Absence of a diagnostic interview…Absence of a diagnostic interview… Lack of objective measures to rate Lack of objective measures to rate

socioeconomic statussocioeconomic status


EdutainmentEdutainmentpartnership with big partnership with big businessbusiness


Not safe...Not safe...

when asked directly about outdoor when asked directly about outdoor play, Turkish moms are significantly play, Turkish moms are significantly more likely to report that they are more likely to report that they are concerned that their child would beconcerned that their child would be::

““unsafe,” 83% TUR; 65% Global unsafe,” 83% TUR; 65% Global ““get hurt,” 75% TUR; 57% Global get hurt,” 75% TUR; 57% Global ““get sick” 48% TUR; 31% Globalget sick” 48% TUR; 31% Global


Across the countryAcross the country SporOMO İle 2004’ten bu yana ziyaret edilen illerSporOMO İle 2004’ten bu yana ziyaret edilen iller– Kayseri, Eskişehir, Diyarbakır, Antalya, Trabzon, Gaziantep, Kayseri, Eskişehir, Diyarbakır, Antalya, Trabzon, Gaziantep,

Samsun, Malatya, Denizli, Mersin(2 kere), Konya, Sivas, Ankara, Samsun, Malatya, Denizli, Mersin(2 kere), Konya, Sivas, Ankara, İstanbul, İzmir, Bursa, Edirne, Elazığ, Erzurum, Sakaryaİstanbul, İzmir, Bursa, Edirne, Elazığ, Erzurum, Sakarya

participants “1.000.000”


C

E

The activity areaThe activity area


“education andtraining”


Is there any effect ?Is there any effect ?


Take home message:Take home message:

we do not yet know about the generalizability we do not yet know about the generalizability of our impressions and limited findings. of our impressions and limited findings. But:But:

while waiting for funds, government agencies, while waiting for funds, government agencies, international collaborations to provide international collaborations to provide support for our activitiessupport for our activities

We can get aboard on the bandwagon of We can get aboard on the bandwagon of other agencies of different agendas moving other agencies of different agendas moving in the same direction that may serve to our in the same direction that may serve to our goals of improving the community’s goals of improving the community’s understanding and improving child mental understanding and improving child mental health.health.


www.yankiyazgan.com 1

A community activation across the country

• An entertainment activity of experiential learning of how play can be of value,

• That will provide:

• A knowledge base to reduce anxiety

• A safe entertainment base to catalyse the flow of information to parents and teachers

• And convenience !!


The CSCThe CSC

A place where I had the opportunity to work A place where I had the opportunity to work with the leaders of the field, best clinicians with the leaders of the field, best clinicians and researchers.and researchers.

supervision and teaching from Phyllis supervision and teaching from Phyllis Cohen, Wayne Downey, Sam Ritvo, Kyle Cohen, Wayne Downey, Sam Ritvo, Kyle Pruett, Joe SaccioPruett, Joe Saccio

clinical work and consultation with/under clinical work and consultation with/under Linda Mayes, Fred Volkmar, Joe Woolston, Linda Mayes, Fred Volkmar, Joe Woolston, Robert King, Melvin Lewis, Steve Marans, Robert King, Melvin Lewis, Steve Marans, Larry VitulanoLarry Vitulano

Learned principles of pediatric psychological Learned principles of pediatric psychological assessment from Sara Sparrow, Laurie assessment from Sara Sparrow, Laurie CardonaCardona


Learned to run and manage an inpatient Learned to run and manage an inpatient unit from the nursing staff and social unit from the nursing staff and social work/family tx group of W1work/family tx group of W1

Worked together with Bob Schultz, Brad Worked together with Bob Schultz, Brad Peterson, Dorothy Grice Peterson, Dorothy Grice

Learned about neuroscience as applied to Learned about neuroscience as applied to child psychiatry from James Leckman, Larry child psychiatry from James Leckman, Larry Scahill, Paul Lombroso, Flora Vaccarino, Scahill, Paul Lombroso, Flora Vaccarino, David Pauls, and Donald CohenDavid Pauls, and Donald Cohen

responsive research: how trying to meet contextual needs dictated my research agenda

Health & Medicine

lack of focus

contextual needs

new research area

line of research

responsive research

evergrowing adhd population

turkish population

research agendayanki