Outpatient Child Research Articles

Implementation of Home-Based Telemental Health in a Large Child Psychiatry Department During the COVID-19 Crisis.

Objective: Telemental health (TMH) is not well described for mental health service delivery during crises. Most child and adolescent psychiatry training programs have not integrated TMH into their curricula and are ill equipped to respond during crises to their patients' needs. In this study, we present the implementation of a home-based TMH (HB-TMH) service during the COVID-19 pandemic. Methods: We describe the technological, administrative, training, and clinical implementation components involved in transitioning a comprehensive outpatient child and adolescent psychiatry program to a HB-TMH virtual clinic. Results: The transition was accomplished in 6 weeks. Most in-clinic services were rapidly moved off campus to the home. Owing to challenges encountered with each implementation component, phone sessions bridged the transition from in-clinic to reliable virtual appointments. Within 3 weeks (March 20, 2020) of planning for HB-TMH, 67% of all appointments were conducted at home, and within 4 weeks (March 27, 2020), 90% were conducted at home. By week 6 (April 3, 2020), reliable HB-TMH appointments were implemented. Conclusions: The COVID-19 pandemic crisis created the opportunity to innovate a solution to disrupted care for our established patients and to create a resource for youth who developed problems during the crisis. Our department was experienced in providing TMH services that facilitated the transition to HB-TMH, yet still had to overcome known and unanticipated challenges. Our experience provides a roadmap for establishing a HB-TMH service with focus on rapid implementation. It also demonstrates a role for TMH during (rather than after) future crises when usual community resources are not available.

Are parents\u2019 geographical origin associated with their evaluation of child and adolescent mental health services? Results from a national survey in Norway

The objective was to assess the association between parents’ geographical origin and their evaluation of outpatient child and adolescent mental health services (CAMHS). Data were collected in a national parent’s experience survey of all outpatient CAMHS in Norway in 2017. Following exclusions, 16,143 parents were part of the study, of which 5932 responded (36.1%). Diagnosis and global psychosocial functional level were collected from the National Patient Register. Multilevel regression was used to assess the association between parents’ geographical origin and parent evaluation of the outpatient CAMHS on ten indicators. Sentiment and content analysis was conducted on open-ended comments from parents. The estimated regression coefficients showed that parents born in Eastern Europe scored the services significantly poorer than parents born in Norway on outcome of treatment (− 7.73, p < 0.01), general satisfaction (− 5.53, p < 0.05), ease of getting in contact with health personnel outside of scheduled appointments (− 17.04, p < 0.001), and knowledge of the services that the child has received at the service (− 10.63, p < 0.001). Parents born in Asia/Africa/South America scored the services similar as Norwegian parents on eight of ten indicators, better on one (waiting time) and poorer on one (ease of getting in contact). Sentiment analysis showed that 54% of the comments from parents born in Eastern Europe were negative, compared to 42% for the Norwegian group and 36% for Asia/Africa/South America. The parents’ evaluation of the outpatient CAMHS were partly associated with their geographical origin, with parents born in Eastern Europe reporting poorer experiences than parents born in Norway.

The impact of Theraplay® therapy on parent-child interaction and child psychiatric symptoms: a pilot study

ABSTRACT Theraplay® is a short-term parent–child interaction therapy combining structured, attachment-based, joyful and adult-led playful sessions with reflective guidance work with the parents. This pilot study evaluates the impact of Theraplay® therapy in improving the quality of parent–child interaction and decreasing the internalizing and externalizing symptoms of children diagnosed with emotional and/or behavioral disorders. Participants were eighteen 4–8 year-old children (M = 4.42, SD = 1.54) from two outpatient child psychiatric clinics whose mothers, and in 13 of those cases fathers also participated in the Theraplay® therapy together with the child. Pre- and post-treatment measures included videotaped observations of parent–child interaction quality, and child psychiatric symptoms (CBCL). The results showed improvements in parent–child interaction quality as well as decreases in children's internalizing and externalizing symptoms. The results of this pilot study indicate that Theraplay® therapy may be an effective treatment among children diagnosed with emotional and/or behavioral psychiatric disorders.

Quality of Antenatal Care Services in a Developing Country: A Cross-Sectional Survey.

The global adult lifetime risk of maternal mortality is 1 in 180; in Pakistan, it is 1 in 170; in developed regions, 1 in 4,900 (Alkema et al., 2016; Filippi, Chou, Ronsmans, Graham, & Say, 2016; World Health Organization [WHO], 2015). The differences in maternal mortality between developed and developing countries are mainly due to the quality of antenatal care (ANC) available in the two groups of countries. The purpose of this study was to assess the structural and procedural quality of ANC services provided and to assess satisfaction levels of women receiving ANC services in two large hospitals in Islamabad, Pakistan. A cross-sectional survey was conducted at the hospitals' outpatient maternal and child health clinics, with a random sample of 138 women. The overall quality of ANC was rated as good (61%), average (17.5%), or poor (17.5%). The findings suggest a need to cultivate quality of care at public health facilities, train health workers in communication skills, and build technical capacity by continuing education and supportive supervision to train health-care providers to follow standard protocols for provision of quality ANC services.

Task-Sharing Between Pediatricians and Non-Physician Healthcare Professionals in Outpatient Child Health Care in Germany: Assessment of Need and Acceptance for Concept Development.

Although pediatricians in Germany work as general practitioners for children, they are planned and trained as medical specialists. In consequence, distances between practices and residences of patients can be very large. The implementation of task-sharing models is a promising option to sustain pediatric outpatient care in rural regions. In this study we assessed the need for and acceptance of delegation of tasks in outpatient pediatric healthcare to non-physician healthcare professionals and developed a task-sharing concept. A standardized questionnaire was developed and addressed a wide range of healthcare professionals. On the basis of the results of the questionnaire and a subsequent workshop involving representatives of the various fields of pediatric care a delegation-concept was developed. A total of 206 questionnaires were answered (response rate: 17%). About 70% of the respondents (n = 145) agreed with the delegation of counseling on prevention, 66% (n = 135) with the delegation of tasks in the transition process into adult medicine. All proposed tasks were conceivable for at least a third of the respondents. Mostly, pediatricians could envision delegation more than the non-physician health care professionals. A three-dimension-delegation-concept was developed: which tasks can be delegated to whom in which setting. Basically, if nurses or medical practice assistants are adequately qualified, all tasks can be delegated to both. The delegation was approved by most of the respondents. Implementation of task-sharing provides a new option to support pediatricians and create better access to outpatient pediatric health care in rural regions. The next step should be the implementation of the delegation concept in pilot projects.

Human Papilloma Virus Vaccination After Pediatric Sexual Abuse Evaluations in the Outpatient Child Sexual Abuse Subspecialty Clinic: A Quality Improvement Project.

The nonavalent human papilloma virus (HPV) vaccination prophylactically contributes to the prevention of nine types of HPV-associated oral and genital cancers. HPV vaccination rates remain lower than the national Healthy People 2020 goal of 80%. Victims of pediatric sexual abuse are at a higher risk for acquiring and developing HPV-related outcomes. Current research supports vaccination after sexual abuse as soon as eligible and suggests utilizing multiple types of medical encounters to increase vaccination rates.An institutional-review-board-approved quality improvement project was developed to determine the impact of promoting and providing HPV vaccination during the medical encounter after pediatric sexual abuse in a child protection team (CPT) clinic. Twenty percent of the 111 total clinic patients evaluated in the preintervention period and 21% of the 99 patients evaluated in the postintervention period were HPV vaccine eligible, illustrating a significant opportunity for impact. During the intervention period, 62% of patients who were vaccine eligible and presented for their CPT clinic visit received HPV vaccine. Barriers to vaccination in the outpatient CPT clinic setting included high appointment no-show rates, high social and medical visit complexity, and absence of an appropriate consenting caretaker. Implications for forensic nursing practice are discussed.

22.4 TRADING PLACES FOR A BETTER OUTCOME: A MOBILE SCHOOL-BASED MENTAL HEALTH CLINIC

Early identification and treatment of mental illness has been shown to improve health and academic performance. Attrition rates in clinics for children with behavioral problems range from 35 percent to 75 percent. In 2016, the University of Florida, College of Medicine, Jacksonville’s (UFJAX) Department of Psychiatry launched its School Psychiatry Program (UFSPP) in Duval County’s Pride Academy Schools (PAS). These schools service children with the most severe behavioral problems in the county. This presentation will describe the UFSPP, compare attendance and parent satisfaction data to outpatient child psychiatry clinics (OCPCs), and discuss efforts to address attrition.

3.1 TOWARDS DEVELOPING A FRAMEWORK FOR ANALYZING HIGH-RISK INCIDENTS IN A CHILD AND ADOLESCENT OUTPATIENT PSYCHIATRY CLINIC

The objectives of this presentation are: 1) to present a framework by which high-risk incidents in an outpatient setting can be collected and analyzed with the aim of improving service delivery through continuous quality improvement initiatives; and 2) to identify modifiable risk factors in patients who attempted suicide in an outpatient child mental health clinic.

Patterns of psychiatric morbidity among children and adolescents presenting to an outpatient child and adolescent mental health service (CAMHS) in a Teaching Hospital in Colombo, Sri Lanka-Challenges and implications for service development.

Patterns of psychiatric morbidity among children and adolescents presenting to an outpatient child and adolescent mental health service (CAMHS) in a Teaching Hospital in Colombo, Sri Lanka-Challenges and implications for service development.

Factors related to parental pre-treatment motivation in outpatient child and adolescent mental health care

The aim of this study was to investigate the relation between a variety of child, parent, family and environmental factors and pre-treatment motivation of parents of children and adolescents newly referred to a mental health care clinic in The Netherlands. Data were collected of 521 parents most involved in the upbringing of the child (443 mothers and 78 fathers; Dutch origin 97.1%) of 207 girls and 314 boys (age M = 10.2, range 1–18 years). Treatment motivation was measured by the Parent Motivation Inventory. Least absolute shrinkage and selection operator (LASSO) regression was used to investigate the prediction strength of 33 factors in 5 domains: (1) source of referral and prior use of healthcare services, (2) child characteristics, (3) characteristics of the primary parent, (4) parenting characteristics of the primary parent, and (5) family characteristics. Twenty-one factors were statistically relevant, explaining 21.3% of the deviance in pre-treatment motivation. Child characteristics, mainly type and severity of problems, contributed most to the model. Notably, internalising problems contributed more than externalising problems. Furthermore, we found relations between parental pre-treatment motivation and parents' perceived self-efficacy, parents' perceived parenting competence, financial problems and source of referral. Our findings provide insight into the multifacetedness of parental motivation prior to starting treatment and inform health professionals of specific contextual factors of interest in parents' readiness to change their behaviour and participate in treatment.

Gifted Children with ADHD: How Are They Different from Non-gifted Children with ADHD?

The present study focused on inattention and hyperactivity/impulsivity differences of gifted children with and without attention deficit-hyperactivity disorder (ADHD). Based on clinical assessment utilizing the Anxiety Disorders Interview Schedule for Children (ADISC-IV) and the Wechsler Intelligence Scale for Children—Fourth Edition, attendees of a public outpatient child service (boys = 359, girls = 148), with mean age 10.60 years (SD = 3.08 years), were allocated into four groups: ADHD (N = 350), gifted (N = 15), gifted/ADHD (N = 18), and clinical controls (N = 124). The Strengths and Weaknesses of ADHD-Symptoms and Normal Behavior Scale dimensionally assessed inattention and hyperactivity/impulsivity variations. Compared to the gifted/ADHD group, the ADHD group had higher scores for inattention and comparable scores for hyperactivity/impulsivity. For most symptoms, the ADHD groups (gifted or not) rated higher than the non-ADHD groups (control and gifted without ADHD). Findings appeared to indicate that (i) ADHD is a valid diagnosis among children who are gifted, (ii) gifted children might tend to be less inattentive than non-gifted ADHD children, and (iii) ADHD-gifted children appear to differ from the non-ADHD-gifted children with regard to specific hyperactive and impulsive behaviors. The practical implication of these findings is that clinicians may wish to focus on these symptoms when diagnosing ADHD among children with high intelligence.

Emotion regulation group skills training for adolescents and parents: A pilot study of an add-on treatment in a clinical setting.

Difficulties with emotion regulation have been identified as an underlying mechanism in mental health. This pilot study aimed at examining whether group skills training in emotion regulation for adolescents and parents as an add-on intervention was feasible in an outpatient child and adolescent psychiatric clinic. We also investigated if the treatment increased knowledge and awareness of emotions and their functions, increased emotion regulation skills and decreased self-reported symptoms of anxiety and depression. Six skills training groups were piloted with a total of 20 adolescents and 21 adults. The treatment consisted of five sessions dealing with psychoeducation about emotions and emotion regulation skills training. Paired-samples t test was used to compare differences between before-and-after measures for adolescents and parents separately. The primary outcome measure, Difficulties in Emotion Regulation Scale, showed significant improvement after treatment for both adolescents and parents. For adolescents, measures of alexithymia were significantly reduced. Also, emotional awareness was significantly increased. Measures of depression and anxiety did not change. In conclusion, group skills training as an add-on treatment can be feasible and effective but further studies are needed.

Translating Discoveries in Attention-Deficit/Hyperactivity Disorder Genomics to an Outpatient Child and Adolescent Psychiatric Cohort

ObjectiveGenomic discoveries should be investigated in generalizable child psychiatric samples in order to justify and inform studies that will evaluate their use for specific clinical purposes. In youth consecutively referred for neuropsychiatric evaluation, we examined 1) the convergent and discriminant validity of attention-deficit/hyperactivity disorder (ADHD) polygenic risk scores (PRSs) in relation to DSM-based ADHD phenotypes; 2) the association of ADHD PRSs with phenotypes beyond ADHD that share its liability and have implications for outcome; and 3) the extent to which youth with high ADHD PRSs manifest a distinctive clinical profile.MethodParticipants were 433 youth, ages 7–18 years, from the Longitudinal Study of Genetic Influences on Cognition. We used logistic/linear regression and mixed effects models to examine associations with ADHD-related polygenic variation from the largest ADHD genome-wide association study to date. We replicated key findings in 5,140 adult patients from a local health system biobank.ResultsAmong referred youth, ADHD PRSs were associated with ADHD diagnoses, cross-diagnostic ADHD symptoms and academic impairment (odds ratios ∼1.4; R2 values ∼2%–3%), as well as cross-diagnostic variation in aggression and working memory. In adults, ADHD PRSs were associated with ADHD and phenotypes beyond the condition that have public health implications. Finally, youth with a high ADHD polygenic burden showed a more severe clinical profile than youth with a low burden (β coefficients ∼.2).ConclusionAmong child and adolescent outpatients, ADHD polygenic risk was associated with ADHD and related phenotypes as well as clinical severity. These results extend the scientific foundation for studies of ADHD polygenic risk in the clinical setting and highlight directions for further research.

A randomized controlled trial of a brain-computer interface based attention training program for ADHD.

ObjectiveThe use of brain-computer interface in neurofeedback therapy for attention deficit hyperactivity disorder (ADHD) is a relatively new approach. We conducted a randomized controlled trial (RCT) to determine whether an 8-week brain computer interface (BCI)-based attention training program improved inattentive symptoms in children with ADHD compared to a waitlist-control group, and the effects of a subsequent 12-week lower-intensity training.Study designWe randomized 172 children aged 6–12 attending an outpatient child psychiatry clinic diagnosed with inattentive or combined subtypes of ADHD and not receiving concurrent pharmacotherapy or behavioral intervention to either the intervention or waitlist-control group. Intervention involved 3 sessions of BCI-based training for 8 weeks, followed by 3 training sessions per month over the subsequent 12 weeks. The waitlist-control group received similar 20-week intervention after a wait-time of 8 weeks.ResultsThe participants’ mean age was 8.6 years (SD = 1.51), with 147 males (85.5%) and 25 females (14.5%). Modified intention to treat analyzes conducted on 163 participants with at least one follow-up rating showed that at 8 weeks, clinician-rated inattentive symptoms on the ADHD-Rating Scale (ADHD-RS) was reduced by 3.5 (SD 3.97) in the intervention group compared to 1.9 (SD 4.42) in the waitlist-control group (between-group difference of 1.6; 95% CI 0.3 to 2.9 p = 0.0177). At the end of the full 20-week treatment, the mean reduction (pre-post BCI) of the pooled group was 3.2 (95% CI 2.4 to 4.1).ConclusionThe results suggest that the BCI-based attention training program can improve ADHD symptoms after a minimum of 24 sessions and maintenance training may sustain this improvement. This intervention may be an option for treating milder cases or as an adjunctive treatment.

199. RDoC-Informed Translation of Genomic Discoveries to an Outpatient Child Psychiatry Cohort

For a range of psychiatric diagnoses, studies have identified a polygenic component of risk, reflecting the aggregate influence of potentially thousands of small-effect common genetic variants. As anticipated by NIMH’s RDoC framework, scores based on this polygenic component do not track precisely with DSM diagnostic boundaries. Yet, such scores may still have clinical value as objective risk indicators and tools for risk stratification. Here, we report an RDoC-informed investigation of polygenic risk scores (PRS) for ADHD and bipolar disorder (BPD) for this purpose in an outpatient child psychiatry cohort.

Parenting styles, perceived social support and emotion regulation in adolescents with internet addiction

AimThe aim of this study is to investigate parental attitudes, perceived social support, emotion regulation and the accompanying psychiatric disorders seen in adolescents who, having been diagnosed with Internet Addiction (IA), were referred to an outpatient child and adolescent psychiatric clinic. MethodsOf 176 adolescents aged 12–17, 40 were included in the study group. These scored 80 or higher on Young's Internet Addiction Test (IAT) and met Young's diagnostic criteria for IA based on psychiatric interviews. Forty adolescents who matched them in terms of age, gender and socio-economic level were included in the control group. The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-PL), the Parenting Style Scale (PSS), the Lum Emotional Availabilty of Parents (LEAP), the Social Support Appraisals Scale for Children (SSAS-C), the Difficulties in Emotion Regulation Scale (DERS) and the Toronto Alexithymia Scale-20 (TAS-20) were applied. ResultsThe results showed that the parents of adolescents with IA were more frequently inadequate in acceptance/involvement, supervision/monitoring and they had less emotional availability. The adolescents with IA had less perceived social support, greater difficulty in the identification and verbal expression of their feelings and emotion regulation. Lower parental strictness/supervision, higher alexithymia and the existence of an anxiety disorder were found to be significant predictors of IA. Internet addicted adolescents with comorbid major depressive disorder had higher levels of alexithymia and lower levels of emotional availability in their parents. ConclusionIt can be concluded that strategies for the prevention and treatment of IA in adolescents should focus on improving the quality of parenting parent-adolescent relationships, enhancing perceived social support and emotion regulation while reducing the associated psychiatric symptoms in adolescents.

Adapting Well-Being into Outpatient Child Psychiatry.

Traditional child psychiatry practices focus on children's symptoms and families' deficits. Focusing on goals and strengths can prepare patients and families for what they can do to enhance their health. The evidence-base for well-being practices supports integration into contemporary practice. Practical guidelines are described for using the initial assessment to address well-being practices, and to plan treatment with psychoeducation, motivational interviewing, and ongoing monitoring. Engaging and effective clinical strategies can further support and build patient and family well-being.

SA83 - EFFECT OF PSYCHOGENOMIC TESTING ON MEDICATION TRIALS AND RESPONSE IN CHILD AND ADOLESCENT OUTPATIENT PSYCHIATRY

Background The significance of psychogenomic testing at clinical practice is still under investigations. Therefore, we thought to evaluate the role of psychogenomic testing in the management of children and adolescents seeking mental health care in the outpatient Child and Adolescent Psychiatry (CAP) clinic. Methods We selected patients who received psychogenomic testing and had regular follow-ups at the clinic for 6 to 8 month period. Among 4 board certified child psychiatrists at the clinic, 151 patients met the inclusion criteria. We examined their psychiatric diagnoses, medications history, and reviewed the CYP450 profile; including 2D6, 2C9, 2C19, 3A4, also 5HT transporter (SLC6A4), 5HT receptor (HTR2A), COMT, ADRA2A and MTHFR genes. We evaluated how the results impacted the clinical care for our patients. We also assessed the number of medications added, eliminated, switched or titrated and the time to achieve clinical improvement. Results In our sample, the average age was 12.9 years, and it ranged from 5 to 19 years-old. 78 subjects were male (52%) vs. 73 female (48%). 25% of patients were diagnosed with Major Depressive Disorder (MDD), 47% with ADHD, 26% with Anxiety disorder, and 2% with other diagnoses. The average number of medications for each specific disorder before testing was 1.47 medications and after testing was 1.83 medications. The total number of medication change in MDD was 0.22, & it made significant improvement in patients with mean CGI response of 3.08 (p= 0.028, df= 1, 35). Whereas number of medication trial did not have significant impact on the outcome of treatment of ADHD and Anxiety who had total number of medication change 0.07 and -0.25 respectively, & mean CGI response of 2.79 & 2.38 respectively (p= 0.39). In MDD, the CYP2D6 status (normal vs abnormal metabolizer) significantly affected improvement (p= 0.025), whereas CYP2C19, COMT & MTHFR status did not affect improvement. However, response to ADHD & Anxiety treatment was not related to psychogenomic testing status. In ADHD, the COMT status (normal vs abnormal metabolizer) did not significantly affect improvement (p= 0.7923). Discussion In our study population, psychogenomic testing was an advantageous tool to decrease the number of medication change and improve the CGI response in MDD. Contrary to expectation the increased COMT activity was not associated with better response to treatment in ADHD patients. So, the clinicians should carefully evaluate each gene test result pertinent to the treating disorder.

Clinical profile and maternal depression and anxiety in children and adolescents with intellectual disability: A study from outpatient child psychiatry

Background: With prevalence between 1% and 3%, intellectual disability (ID) not only affects the children and adolescents with this disability but also the caregivers, particularly the mothers. Aims: The aim was to study the clinical profile of children and adolescents with ID along with the prevalence of depressive and anxiety disorders in their mothers. Settings and Design: Cross-sectional descriptive study was conducted in Outpatient child psychiatry clinic. Methodology: Children and adolescents diagnosed with ID by a psychiatrist and clinical psychologist where subjected to a semi-structured questionnaire to record the sociodemographic status, antenatal history, perinatal history, and developmental history, presenting complaints, current behavioral problems, and medical history. Psychiatric comorbidity in the study participants and depression and anxiety disorders in their mothers was also assessed. Results: With the mean age of 8.68 years ± 2.63, majority (81.2%) belonged to the age group of 6–12 years with predominance of boys (60%). Antenatal factors were present in about 18%, whereas perinatal factors were present in about 48%. Delayed developmental history was present in 75%. Psychiatric comorbidity was present in about 32%, whereas current behavioral problems were present in about 47%. Majority (about 71%) had mild ID. Maternal depression and anxiety disorders were present in about 70%. Statistical Analysis: Descriptive analysis was performed with the Statistical Package for the Social Sciences. Conclusion: High rates of antenatal and perinatal factors with a history of developmental delay in a significant number of children and adolescents with ID were found. Mild ID predominated. Behavioral problems, psychiatric comorbidity, and medical comorbidity were frequently observed. Maternal depression and anxiety were also very high.

Neurological symptoms of vitamin B12 deficiency: analysis of pediatric patients.

SUMMARYVitamin B12 is one of the essential vitamins that affect various systems in the body, including the central nervous system. Vitamin B12 plays an important part in the metabolism of the nervous system, although its exact role under pathological conditions is not fully understood. The purpose of this study was to emphasize the importance of early diagnosis of vitamin B12 deficiency in the light of the characteristics of the patients enrolled. This retrospective, clinical study included 38 children with neurological symptoms of vitamin B12 deficiency. Records of 38 patients referred to a single center of the university hospital outpatient child neurology clinic due to neurological symptoms of vitamin B12 deficiency between February 2012 and December 2013 were evaluated retrospectively. Patients aged 0-18 years with symptoms including syncope, dizziness, convulsion, hypotonia, developmental retardation, tremor, ataxia, tingling sensations and paresthesia, blurring of vision, fatigue and concentration difficulty caused by vitamin B12 deficiency were included in the study. Patient neurological findings included syncope (n=6), dizziness (n=4), hypotonia (n=9), inability to sit or walk without support, or gait ataxia (n=2), convulsion (n=4), hand tremor (n=1), tingling sensations and paresthesia (n=3), vision blurring (n=1), fatigue and concentration difficulty (n=8). All patients with neurological symptoms of vitamin B12 deficiency recovered within one month after vitamin B12 supplementation. In conclusion, clinical characteristics of vitamin B12 deficiency are broad and nonspecific and may not be associated with anemia and increased mean corpuscular volume. Since different clinical characteristics can be seen without anemia, awareness and cautious approach are essential in order to avoid severe clinical disease, especially in children from underdeveloped countries.