‘Establishment of Shishu Bikash Kendra
in 14 Medical College Hospitals
FY 2008-2011’

 

Line Directorate: Improved Hospital Services Management
Directorate: Hospitals and Clinics
DGHS, Mohakhali, Dhaka

National Co-ordinator
Naila Zaman Khan
MBBS, FCPS, PhD (London)
Professor and Head, Department of Pediatric Neurosciences
Dhaka Shishu Hospital

Summary
Multidisciplinary (physician, psychologist, therapist) Shishu Bikash Kendra’s have been established in 10 medical college hospitals (MCHs) in 2009 and 2010, including: Dhaka MCH, Suhrawardy MCH, Salimullah MCH, Sylhet MCH, Barisal MCH, Chittagong MCH, Rajshahi MCH, Khulna MCH, Rangpur MCH, and Mymensingh MCH. Increasing numbers of children with a range of developmental problems, impairments and disabilities are benefitting from the service which emphasizes on follow up visits, and functional improvements in motor, vision, hearing, speech, cognition, behavioral domains, and comprehensive management of seizure disorders. Professionals work closely with the family to optimize every child’s developmental potential, improve their quality of life, and prevent disability. Services in seven other MCHs and at the district level are being planned.

Objectives
To prevent disability, optimize development and improve quality of survival of all children in Bangladesh.

Aims
To establish child and family-friendly Shish Bikash Kendro’s (SBK) within key public hospitals across the country.
To procure and train a core team of multidisciplinary professionals, including child health physicians, child psychologists, and developmental therapists, to provide services within these centers.
To apply stardardized tools, methodologies and strategies for early screening, assessment, intervention, treatment and management of the entire range of developmental delays, disorders, impairments and disabilities.
To conduct epidemiological surveys and clinical research with the aim of providing an evidence based health service delivery system and identify causal risk factors to help towards prevention of major childhood disabilities.
To provide psychosocial services to families and empower parents and primary care-providers to optimize their child’s development.
To provide training and strategies to establish linkages with primary health care services.
To develop a digital data-base of information related to child development and disability across Bangladesh.

THE MULTIDISCIPLINARY TEAM
Office Manager/Computer Operator: for record-keeping and epidemiological surveillance,maintaining clnical records

Cleaner: for simulating the home-situation and maintaining cleanliness

Location of 14 Shishu Bikash Kendra’s by FY of establishment

WEEKLY SCHEDULE

Saturday

Sunday

Monday

Tuesday

Wednesday

Thursday
8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am 8.30 to 11.30 am
‘More Than Words’  (MTW) Clinic  Seating and Feeding Clinic (SFC) Low Vision Clinic (LVC) Speech, Language  and Communication (SLC) Clinic Epilepsy/ Encephalopathy  Clinic Well Baby Clinic (WBC)
Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA) Psychological Assessment (PA)
Tea Break: 11.30 to 12 noon
12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm 12 to 2 pm
Psychological Assessment (PA)
Walk-In Clinic (WC)
Psychological Screening (PS) With

General Developmental Assessment (GDA) Clinic

 Psychological Screening (PS) With

General Developmental Assessment (GDA) Clinic
Psychological Assessment (PA)
Walk-In Clinic (WC)
Psychosocial Counseling (PC)  and Mental  Health (MH)
Walk-In Clinic (WC)
Psychosocial Counseling (PC) and Mental Health (MH)
Walk-In Clinic (WC)

THE MULTIDISCIPLINARY TEAM
Abbreviations
GDA = General Developmental Assessment Clinic
WC = Walk-in Clinic
PA = Psychological Assessment Clinic
WBC = Well Baby Clinic
MTW = More Than Words Clinic
SFC = Seating and Feeding Clinic
LVC = Low Vision Clinic
SLC = Speech Language Communication Clinic
DT = Developmental Therapy Clinic
MH = Mental Health Clinic
EP = Epilepsy Clinic
IPD = In-patients department

Attendance by Clinic First 5 SBKs: Aug '09 - December'11; Last 5 SBKs: Sept '10-December'11
 

Follow Up Clinics
  GDA WC PA WBC IPD Total MTW SFC LVC SLC DT EP PA OPD MH Total FU Grand Total
Dhaka 1407 2288 903 3773 0 8371 178 486 553 1718 2304 1769 440 86 1548 9082 17453
Suhrawardy 428 1684 1264 316 7 3699 29 61 58 175 442 312 314 396 120 1907 5606
Salimullah 703 1994 1129 37 54 3917 45 52 64 267 457 614 58 247 12 1816 5733
Sylhet 1247 3107 759 152 27 5292 116 110 109 186 1311 130 55 429 17 2463 7755
Barisal 413 1671 691 93 0 2868 8 77 58 54 833 82 612 1122 20 2866 5734
Chittagong 215 1484 358 88 194 2339 16 117 104 100 728 300 107 569 12 2053 4392
Rajshahi 69 1959 294 25 0 2347 18 17 3 32 1080 218 250 743 0 2361 4708
Khulna 99 968 92 24 17 1200 28 1 10 35 409 148 35 241 0 907 2107
Rangpur 32 1342 131 17 2 1524 9 2 4 92 504 36 68 366 0 1081 2605
Mymensing 111 1533 211 48 175 2078 46 16 62 143 748 193 60 843 0 2111 4189
Total 4724 18030 5832 4573 476 33635 493 934 1025 2802 8816 3802 1999 5042 1729 26647 60282

Number of Attendances in 10 SBKs by Clinic till March, 2011
note: data from 10 GDA Clinics, ie, those children who needed detailed multi-professional assessments

Do SBKs reach the ‘unreached’?
e.g., younger children, girl child, lowest income group

Name of medical college hospital

% less than two years of age

%  female

Monthly family income

<5000 Taka

Dhaka  

N=303

55.44 31.9 66.67
Suhrawardy

N=138

 56.5 35.5 71.01
Salimullah

N=224

 43.75 42.4 58.04
Sylhet

N=443

 54.8 42.43 63.88
Barisal

N=137

54.7 36.5 72.99
note: data from GDA Clinics, ie, those children who needed detailed multi-professional assessments

 

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sbk photo gallery

Shishu Bikash Kendra, Dhaka Medical College Hospital

   
GDA of child with cerebral palsy by Physician and Therapist    
     

Shishu Bikash Kendra, Sir Salimullah Medical College Hospital

   
Psychological Screening (PS) by Psychologist, during a GDA Clinic    
     

Shishu Bikash Kendra, Shaheed Suhrawardy Medical College Hospital

   
Well Baby Clinic (WBC): Neurodevelopmental Assessment of a newborn in the maternity ward  by therapist.  Physician and Psychologist look on.      
     

Shishu Bikash Kendra, MAG Osmany Medical College Hospital, Sylhet

More Than Words (MTW) Clinic for Autism Psychological Assessment (PA) Low Vision Clinic  (LVC)
     

Shishu Bikash Kendra, Sher-e-Bangla Medical College Hospital, Barisal
   
Family with a disabled child attending  the SBK    
     

Shishu Bikash Kendra, Chittagong Medical College Hospital
 
Developmental Therapy Clinic, with psychologist and evaluation team observing National Co-ordinator’s monitoring team in Chittagong SBK  
     

Shishu Bikash Kendra, Khulna Medical College Hospital
 
Developmental Therapist  assessing motor skills Cognitive assessment by child psychologist  
     

Shishu Bikash Kendra, Rajshahi Medical College Hospital
   
The SBK Team: Child Health Physician, Child Psychologist, Developmental Therapist, Office Manager and Cleaner    
     

Shishu Bikash Kendra, Rangpur Medical College Hospital
 
Psychometric Testing by the Child Psychologist General Developmental Assessment by Child Health Physician, Child Psychologist and Developmental Therapist in a child with suspected Autism Spectrum Disorder  
     

Shishu Bikash Kendra, Mymensingh Medical College Hospital
 
Child Health Physician and Developmental Therapist assessing a child’s visuo-motor functions Notice in general OPD to raise awareness regarding SBK services  
 

 

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Evaluation of SBK Services

By
Prof. Helen McConachie
Professor of Clinical Psychology
Newcastle University
and
Dr. Alison Salt
Head, Clinical Neurodisability Services
Great Ormond Street Hospital for Children
Institute of Child Health
University College Hospital, London
28 April – 7 May 2011

Evaluation of Services: SBK Suhrawardy MCH, Dhaka, 30 April, 2011
     

Evaluation of Services: SBK, Osmany MCH, Sylhet, 2 May 2011
     

Evaluation of Services: SBK, Salimullah MCH, 3 May, 2011
     
     

Evaluation of Services: SBK, Dhaka MCH, 3 May, 2011
     

Evaluation of Services: SBK, Chittagong MCH, 4 May, 2011
   
     

Evaluation Feedback to the Trainers, Department of Pediatric Neuroscience, Dhaka Shishu Hospital, 5 May, 2011
   
     

Meeting at the Line Director’s Office, Improved Hospital Services Management, Hospitals and Clinics, DGHS, 5 May, 2011
   
     
 

 

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Epidemiological Survey of
Childhood Impairments and
Disabilities around
5 Medical College Hospitals

January to June,  2010
Funded by: Planning and Research Line Directorate, DGHS

Study Children: 0-9 years old By door to door survey of underprivileged population living nearest to the MCH
Developmental Screening Questionnaire (DSQ) for 0-<2 years; Ten Questions Plus (TQP) for 2-9 year olds, asked to mothers by community workers

Children: Gender Ratio in screened children compared to those availing services in SBKs

Children: proportion <2 years versus =>2 years in survey and <2 year olds availing SBK services

% screened positive for NDIs by age group
2-9 year olds at-risk for NDIs = 8.9%
0-<2 year olds at-risk for NDIs = 6.2%
0-9 year olds at-risk for NDIs = 7.5%

% screened positive for NDIs by age group

Screen positive by child’s gender: 2-9 year olds

Prevalence of Neurodevelopmental Impairments
 
DMCH
Salimullah
Suh'wrdy
Sylhet
Barisal
Standard Error

.06

.03

.04

.02

.20
Prevalence per 1000 children

63

90

46

20

97
95% Confidence Interval, Upper - Lower

51-75

85-95

38-54

16-24

57-137
Mean Prevalence = 63 per 1000 (analysis weighted for children not assessed in second stage)

Executive Summary 1

Household Survey
41% were low income (income 3000-5000 Taka)
9.2% were ultra poor (income <3000 Taka)
36% were unskilled workers
6% were female-headed households
42% household head never had schooling
All had =>1-5 decimals of land, except 58% surveyed around Sir Salimullah MCH who had none
93% drank piped water, except in Barisal, where only 3% had this facility
95% used sanitary latrine, except Sylhet, where only 35% had this facility
98% used iodized salt in their food
 

Executive Summary 2

Mother-child Survey
42% had no schooling, lowest in Barisal (13%), highest in Sylhet (67%)
30% had attended primary school, highest in Barisal (37%), lowest in Sylhet (15%)
46% could not read, lowest in Barisal (22%), highest in Sylhet (67%)
75% ‘housewives’, highest around DMCH (82%), lowest in Barisal (64%)
77% did not earn wages, lowest in Barisal (66%), highest around DMCH (87%)
8% consanguinity, highest around Kamrangirchar, Sir Salimullah MCH (15%), lowest in Barisal (1%)
Mean live births =2; highest around Kamrangirchar (2.6), lowest in Geneva Camp (0.17)
 

Executive Summary 3

Children’s Survey Outcomes
Male: Female ratio 1.1, with most disparity in Sylhet (1.3) and negative ratio in Barisal (0.96)
9% disparity between female population in community and those availing services, with minimum disparity in Sylhet (3%), maximum in Salimullah (13%)
19% more <2 year olds, however, seeking SBK services than their proportion in the community survey
9% children aged 2-9 years screened positive for impairments, highest around Suhrawardy (12%), lowest in Sylhet (3%)
6% children aged 0-<2 years screened positive for impairments, highest around Salimullah (13%), lowest in Sylhet (1%)
 

Executive Summary 4

Children’s Survey Outcomes, continued
Higher screen-positivity within low income groups, highest in Suhrawardy (56% in the 3000 to 5000 taka group), lowest in DMCH (2% within the >15000 taka group)
11% higher likelihood of  screen positivity in female-headed households in Dhaka city, with maximum around Salimullah (18%)
No difference in screen positivity within gender categories, in both older and younger children.
 

Executive Summary 5

Risk factors for Screen Positivity
Significant risk factors were related to the following:
–DMCH:
female headed household,  unskilled worker, kutcha house, no land ownership, no source for tapped water, and no sanitary latrine.
Maternal factors: if ‘housewife’
 
–Salimullah:
low monthly income, kutcha house, no loan facilities, poor source of drinking water, and large numbers using one toilet facility
Maternal factors: poor schooling, does not work, no wages, no loans
 
–Suhrawardy:
low monthly income, no land ownership, no consumer items in the house
Maternal factors: none significant
 
–Sylhet:
Low monthly income, no bicycle
Maternal factors: none significant
 
–Barisal
No land ownership, kutcha house, no bicycle
Maternal factors: Cannot read or reads with difficulty
 

Executive Summary 6

Prevalence of Childhood Neurodevelopmental Impairments and Disabilities
63 per 1000 children were found to have => one neurodevelopmental impairment across the five study sites
Highest in Barisal (96 per 1000) and around Salimullah MCH, ie on the banks of the river Buriganga in Kamrangirchar (90 per 1000); lowest in Sylhet (20 per 1000). Data could be skewed due to less attendance of screen negatives.
Covert’ or ‘unrecognised’  impairments were most commonly diagnosed in the assessed children. These were:
   
 
–DMCH: Cognition (67%), Gross Motor (24%)
 
–Salimullah: Cognition (55%), Speech (18%)
 
–Suhrawardy: Cognition (24%), Gross Motor (19%)
 
–Sylhet: Cognition (24%), Speech (24%)
 
–Barisal: Seizures (30%), Cognition (24%)
 

Executive Summary 7

Associated Factor: Stunting
41% assessed children were stunted
Highest around Salimullah (57%) and DMCH (52%), and lowest in Sylhet (18%)
 

Study Limitations
Numbers per site were too small for estimating risk factors. They need to be pooled together for further analysis.
Over half of children (screen positives and controls) could not be assessed at the SBKs as they either defaulted (parent’s could not be convinced to bring their children)
 

Study Implications 1
Door to door surveys by CWs are able to find most vulnerable populations of children, ie, lowest income/poorest, younger, girl child, and those with unrecognized developmental delays and impairments. Establish social equity.
Poverty-related factors have significant association with children at-risk for NDIs (Islam et al, 1995; Durkin et al, 2000; Grantham-McGregor et al, 2007)
Dhaka city poor have most significant associations between poverty and risk for NDIs
Children from female-headed households are more vulnerable; also whose mothers are unable to read; those without a job or source of income.
 

Study Implications 2

One in ten children  will screen positive for a NDI of whom an estimated two-third may have a definite impairment on further assessment.
Commonest impairments are ‘covert’ ‘unrecognized’ ‘not apparent’ to parents, ie, related to cognitive deficits, speech delay.
Close links with stunting (Walker et al, 2007), which is prevalent in almost half of the assessed children. 
 
–Largest implication for school enrollment and dropout, where 48% do not complete primary school (Bangladesh Education Watch, 2008)
NO SURVEY WITHOUT SERVICES: As this increases maternal stress and their psychiatric morbidity (Khan et al, 2010)
Need for services and early intervention found in this study, as ratio of <2 year olds brought to SBKs more than their ratio found in the community.
 

Study Implications 3

Multidisciplinary Shishu Bikash Kendra’s close to the community may be able to reverse >80% of these children’s impairments (Operational Plan, HNPSP, DGHS, MOHFW)
Large prospective studies are needed to provide such an evidence within Bangladesh
Field workers can be taught to administer the simple validated questionnaires  used in this study, in children’s homes, to screen children for early NDIs. For example in 13500 working from Community Clinics.
Screen-positive children can be assessed at home or within their community by CWs, using tools validated by Bangladeshi researchers (Khan et al, 2010; Khan et al, awaiting submission). Simple home-based interventions (eg. ‘positive parenting’, interactive play, story telling), validated in many studies world-wide (Maulik and Darmstadt, 2009), may be applied to these children
 

Conclusion
Home-based screening and early intervention to establish a tiered system of referral will be able to provide a ‘DEVELOPMENTAL SAFETY NET’ and an ‘INTEGRATED MANAGEMENT OF CHILD DEVELOPMENT’ (IMCD) for all children in Bangladesh
 

References
Durkin MS, Khan NZ, Davidson LL, Huq S, Munir S, Rasul E, Zaman SS. Prenatal and postnatal risk factors for mental retardation among children in Bangladesh. Am J Epidemiology 1;152(11):1024-33, December 2000.
Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369(9555):60-70.
Islam S, Durkin MS, Zaman SS. Socioeconomic Status and the Prevalence of Mental Retardation in Bangladesh. Mental Retardation. 1993; 31 (6): 412 – 417.
Khan N, Durkin M. Framework: Prevalence. In: (eds: P Zinkin and H McConachie) Disabled Childre and Developing Countries. Clinics in Developmental Medicine No. 136. Pages 1-9. MacKeith Pres.]London, 1995.
Khan NZ, Muslima H, Begum N, Begum N, Shilpi AS, Batra M, Darmstadt GD. Validation of Rapid Neurodevelopmental Assessment Instrument for under-two-year-children in Bangladesh.. Pediatrics 2010 Apr;125(4):e755-62. Epub 2010 Mar 22.
Khan NZ, Muslima H, Bhattacharya M, Darmstadt G, et al. Stress In Mothers Of Preterm Infants In Bangladesh: Associations With Family, Child And Maternal Factors And Children's Neurodevelopment. Child Care Health Dev. 16 May, 2008; 34 (5): 657- 664.
Khan NZ, Muslima H, et al. Validation of a home-based neurodevelopmental screening tool for under 2 year old children in Bangladesh. Pediatrics (submitted in Sept 2010)
Maulik PK, Darmstadt GL. Community-based interventions to optimize early childhood development in low resource settings. J Perinatol. 2009 Aug; 29(8):531-42. Epub 2009 Apr 30. Review.
Shrout PE, Newman S.  Design of two-phase prevalence surveys of rare disorders. Biometrics, 1989; 45:549-555.
UNICEF. Monitoring Child Disability in Developing Countries. Results from the Multiple Indicator Cluster Surveys. 2008. United Nations Children’s Fund. Division of Policy and Practice, New York, USA.
UNICEF. State of the World’s Children, 2007. New York.
Walker SP, Wachs TD, Gardner JM, et al. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007; 369(9556):145-157.
World Health Organization International Classification of Functioning, Disability and Health., Geneva, 2001.
Zaman SZ, Khan NZ, Islam S, Banu S, Dixit S, Shrout P, Durkin M. Validity of the “Ten Questions” for screening serious childhood disability: results from urban Bangladesh. Int J Epidemiology. 19: 613-620, 1990.

 

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