title: Cerebral malaria is associated with long-term mental health disorders: a cross sectional survey of a long-term cohort.
abstract: BACKGROUND
  Cerebral malaria (CM) and severe malarial anaemia (SMA) are associated with neuro-developmental impairment in African children, but long-term mental health disorders in these children are not well defined.
  
  
  METHODS
  A cohort of children previously exposed to CM (n = 173) or SMA (n = 99) had neurologic assessments performed and screening for behaviour difficulties using the Strengths and Difficulties Questionnaire (SDQ) a median of 21 months after the disease episode. These findings were compared to concurrently recruited community children (CC, n = 108). Participants with SDQ total difficulties score ≥ 17 had a mental health interview with the child and adolescent version of the Mini-International Neuropsychiatric Interview (MINI-KID) and a sample had brain magnetic resonance imaging (MRI).
  
  
  RESULTS
  Fifty-five children had SDQ score ≥ 17. On the MINI-KID, these children were classified as having no difficulties (n = 18), behaviour difficulties only (n = 13) or a mental health disorder (n = 24). Behaviour difficulties were seen in similar frequencies in CM (3.5%), SMA (4.0%) and CC (2.8%). In contrast, mental health disorders were most frequent in CM (10.4%), followed by SMA (4.0%) and CC (1.8%). Externalizing disorders (conduct, oppositional defiance and attention deficit hyperactivity) were the most common mental health disorders. The median total coma duration was 72 (IQR 36.0-115.0) h in patients with mental health disorders compared to 48 (IQR 28.5-78.7) h in those without, p = 0.039. Independent risk factors for mental health disorder included neurologic deficit at discharge (OR 4.09 (95% CI 1.60, 10.5) and seizure recurrences during hospitalization, (OR 2.80, 95% CI 1.13, 6.97). Brain MRI findings consistent with small vessel ischaemic neural injury was seen in over half of these children.
  
  
  CONCLUSIONS
  Cerebral malaria may predispose children to mental health disorders, possibly as a consequence of ischaemic neural injury. There is urgent need for programmes of follow-up, diagnosis and interventions for these children.
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda. ridro1@gmail.com.
authors.forename: Richard
authors.initials: R
authors.lastname: Idro
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.|Neuropediatric Research Unit, Astrid Lindgren Children's Hospital, Karolinska Institutet, Solna, Stockholm, Sweden.
authors.forename: Angelina
authors.initials: A
authors.lastname: Kakooza-Mwesige
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Asea
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Keron
authors.initials: K
authors.lastname: Ssebyala
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Paul
authors.initials: P
authors.lastname: Bangirana
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Opoka
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Samson K
authors.initials: SK
authors.lastname: Lubowa
authors.affiliation: Department of Pediatrics, University of Minnesota, Minneapolis, DE, USA.
authors.forename: Margaret
authors.initials: M
authors.lastname: Semrud-Clikeman
authors.affiliation: Departments of Pediatrics, Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, USA.
authors.forename: Chandy C
authors.initials: CC
authors.lastname: John
authors.affiliation: Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, P.O Box 7072, Kampala, Uganda.
authors.forename: Joyce
authors.initials: J
authors.lastname: Nalugya
mesh_terms: D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007223:Infant; D016779:Malaria, Cerebral / Q000150:complications*; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology* / Q000473:pathology*; D014454:Uganda / Q000453:epidemiology
keywords: Behaviour; Cerebral malaria; Children; Disorder; Mental health; Psychiatric